A newborn baby boy could have survived if medics had delivered him an hour-and-a-half earlier, an inquest has found.
Tragic Ethan Johnson died at just one day-old after “chaos” on the maternity unit saw medics delay before carrying out a Cesarean.
Mum Claire Johnson had gone into Milton Keynes Hospital to be induced four days after reporting she was having contractions.
An inquest into Ethan’s death heard a Cardiotocography(CTG) to test his heartbeat wasn’t started until an hour and 10 minutes after Claire arrived at hospital.
It showed Ethan’s heartbeat was ‘abnormal’, but ‘miscommunication’ between junior and senior staff meant the c-section was delayed.
Coroner Tom Osborne said: “If the decision had been made to take Claire straight to the theatre at 12.45 then Ethan would have been born shortly before one o’clock.
“Is it the case that if Ethan had been born earlier - may have avoided the fall in the foetal heart rate?”
Dr Salma Ibrahim, Registrar in Obstetrics and Gynaecology at the hospital, said: “Possible that he may have been born alive but not sure about the damage to his brain.”
Dr Ibrahim said it was a “lost opportunity to deliver” and Mrs Johnson walked out of the coroner’s office visibly upset.
Miss Nandini Gupta, Consultant Obstetrician and Gynaecologist at the hospital, said: “I am really sorry that we lost Ethan.”
Tearful mum Claire told the inquest she felt “nobody was in charge” and the maternity wing was in “chaos”.
She said: “I can remember feeling it was chaos.
“I just want the truth about how my son died. If there were mistakes made I want people to be honest about that so they can be fixed.
“I do not want to see other babies dying.
“I would not want anyone else to be put through that.”
Coroner for Milton Keynes Tom Osborne said there was a “missed opportunity” to save Ethan’s life.
He said he will write a ‘prevent further death’ report to the hospital, despite its own internal investigation finding the death was ‘unavoidable’.
Mr Osborne said he was “not convinced” there was adequate leadership at the hospital.
He added: “Somebody at every shift has to take responsibility. I am asking the hospital to come up with a plan.
“The delay resulted in a lost opportunity to deliver him earlier – and that is how Ethan came by his death.
“I am confident that something will happen and we can confidently say that because of Ethan Johnson’s death, further deaths will have been avoided.”
He added: “For me this has been one of the most difficult inquests I have had to conduct. I have a grandson who is also called Ethan.”
Recording a narrative verdict, Mr Osborne said: “The delay in his subsequent delivery by caesarean section resulted in a lost opportunity to deliver him earlier and render further medical treatment.”
Claire was due to give birth on Christmas eve 2014, but after going over the due date an induction was planned for January 4, 2015.
Ethan died following meconium asphyxiation - the process where a baby inhales faeces into their lungs from the fluid found inside the womb.
A secondary cause of death was given as perinatal asphyxia.
The family’s solicitor, Gary Williams of Osborne Morris & Morgan, said: “Ethan’s death was reviewed internally by the hospital.
“That investigation concluded his death was unavoidable, but Ethan’s family felt this investigation left many questions unanswered and issues unaddressed.
“As a result of the inquest hearing, Mrs Johnson now feels that she has a much better understanding of what happened on the day Ethan was born, what the risks were and what could have been done to change what happened.”
After the coroner recorded a narrative verdict, MK Hospital issued a statement.
Mr Ed Neale, divisional director for women’s and children’s services at the hospital, said: “We are extremely sorry over the sad death of Ethan Johnson and extend our deepest condolences to his parents.
“We will never know whether an earlier delivery would have saved him.
“However, as with any death there are always lessons that can be learned and we will continue with the work we began last year to ensure that we provide the highest quality care for the mothers of Milton Keynes.
“We have been inspected by the Care Quality Commission (CQC), the Royal College of Gynaecologists (RCOG) and the Royal College of Midwives (RCM), who have all confirmed that we have a safe service.
“We will continue to strive for best quality outcomes.”