A heavily-pregnant woman lost one of her twin babies just days after being sent away from hospital after a failed attempt to induce their births, an inquest heard.
Nicola Burr, in her 30s, was discharged from Milton Keynes University Hospital on March 29 last year five days after doctors tried to induce their birth.
The hearing was told that she gave birth to twins on March 31, but tragically one of them died two days later from a cardiac arrest.
The inquest at Milton Keynes coroners’ court was told that Joshua Burr weighed 30% more than his twin-sister Katie but he quickly deteriorated after his birth.
All the scans leading up to his birth indicated he would have been a similar weight to his sister and doctors were shocked when he was born.
Joshua is one of five babies whose deaths are being investigated by hospital chiefs.
Dr Ghaly Hanna, a consultant obstetrician and gynaecologist, told the inquest that things could have been done differently.
Dr Hanna, who cared for the twin’s mother during her pregnancy but was not present in the week before and when she gave birth, said: “I would have been concerned that the induction was not going as it should have been to deliver the baby.
“There is a link between infection and a failure to induce labour only if the water breaks.
“Unfortunately that test was not conclusive but that should have been investigated further.”
He said it was very unusual for a induction not to work for a woman with twins and had never seen it happen in any pregnancy since becoming a doctor in 1988.
Mrs Burr was admitted to Milton Keynes University Hospital on March 24, 2014, when she was 37 weeks pregnant.
She had been due to give birth the following week but this was moved forward after doctors became concerned about her high blood pressure.
She was monitored and put on a CTG - a machine which monitors babies heart rateS.
Katie heart rate was fine but midwife Lauren Dod noticed that Joshua having an abnormal heart rate on two occasions.
Ms Dod, who has been a midwife for around two years, passed this on a doctor.
She said: “She said that wasn’t serious. I wasn’t sure at that point and I was recently qualified so I just thought I was wrong.”
No alarm bells were raised about Joshua’s welfare, despite Mrs Burr telling staff that she had found blood on a sanitary pad.
This was later investigated by midwife Sophie Conneely who saw Mrs Burrs on March 29 at Milton Keynes University Hospital.
She had been given a phone sheet which said that Mrs Burrs thinks she may have broken her waters and was coming into the hospital for assessment.
Ms Conneely did not know any of Mrs Burrs previous history at the hospital and learnt that she had been coming in every day after talking to her.
She put her on a CTG and did not note anything unusual.
Mrs Burrs then prepared to be discharged later than day.
Joshua was born in a poor condition tragically passed away on 2 April last year at John Radcliffe Hospital in Oxford after having been transferred there after birth for further care.
Milton Keynes Hospital NHS Foundation Trust are currently investigating five young babies deaths including Joshua’s which were recorded in an eight month period between 2013 and 2014.
The inquest continues.