Coroner makes ‘Prevention of Future Deaths order’ as a result of maternity failings


September 13, 2021 | By Natalie Cosgrove |

September 13, 2021 | By Natalie Cosgrove |

I previously wrote about the tragic death of Clay Wankiewicz at Doncaster Royal Infirmary. The Coroner investigating Clay’s death and maternity practices at the hospital has now made a ‘Prevention of Further Deaths Order’. This is the highest criticism she can make of the Trust and she spoke specifically about the dangers of ‘confirmation bias’.

The concept of confirmation bias means that we jump too quickly to one particular conclusion and we then tend to favour evidence which supports that conclusion. In practice, what this means in maternity care is that when a particular symptom is reported, staff might diagnose the problem incorrectly. Worse still, rather than look at the whole picture and all symptoms and evidence (which might help rule out certain causes) they proceed to treat what could be the wrong problem. In some cases, including Clay’s, this can have tragic consequences.

The Trust claims to have communicated the dangers of confirmation bias to all staff. However, the Coroner was critical that this was done in the form of a newsletter, which was likely to be ignored by most staff. Worse still, those who gave evidence confirmed that they hadn’t received any training since Clay’s death and they weren’t aware of any changes that the Coroner had been tld had taken place.  Communicating in such a passive manner, such as a newsletter, is woefully inadequate for information that could literally make the difference between life and death.

Clay’s parents, Daniel and Beth have issued the following statement:

Clay is our absolute world and there will always be a missing piece in our family because of he is not with us. We truly believe that had the Trust provided better care, he would be here today.

Clay Bear will be so sadly missed, with his Wreck-It Ralph hands and his perfect cheeks, and he was perfect. We feel at such a loss that he is not with us. We are grateful to the Coroner for her observations and that we did everything that we could to protect our precious son.

There have been other baby deaths arising because of the Trust’s failings. We know that this is something that has been going on before Clay’s death, and we are concerned that it will keep on happening unless change is enacted.

In 2016 the Trust were made aware following a review by Royal College of Obstetrics and Gynaecologists of the systematic issues within maternity services. The Trust never published this and it would appear that the recommendations that the Trust could have acted upon are still issues today. We are pleased this was put before the Coroner because we know that more families are in the same position as us due to the Trusts inability to change.

We are deeply concerned with the evidence of the Trust of changes they propose to make and feel far too little has been done in the 13 months since Clay has died. They don’t appear to accept their failings or make real steps to protect other babies. This is shared in the Coroners concerns regarding confirmation bias and we are grateful to her for the steps she has taken formally to ensure that the Trust make real change.

We encourage any other family who have been put in a similar position to us to seek answers. Nothing will ever take away this pain but we hope in sharing our story that it will give some hope to other families that they are not alone and it wasn’t their fault.

If you need help or advice with any aspects of Medical Negligence, call us on 0800 138 0458 or contact us through the website.

Natalie Cosgrove

Natalie is an Associate Solicitor within our Clinical Negligence team in Sheffield. She qualified as a Barrister in 2008, then cross-qualified as a Solicitor in 2011. She joined Switalskis in November 2016. Natalie's profile