ERRORS made by midwives at Trowbridge Birthing Centre meant that hospital staff had less time to save a three-day-old baby, an inquest was told.

Mum Tracie Akgul, 42, of Eden Vale Road, Westbury, said she feels that her daughter Amirah was failed by staff at the unit after they didn’t refer her baby to a hospital paediatrician for jaundice which could have improved her survival chances when Amirah suffered a pulmonary haemorrhage in June last year.

Although the two conditions are not linked, she wants to make sure an incident like this doesn’t happen again following her daughter’s inquest held at Flax Bourton in Bristol on Friday.

During the hearing, senior coroner Maria Voisin heard evidence from medical staff who treated Amirah within her short life, including Helena Boswell, community midwife at Trowbridge Birthing Centre. She first visited the family at home.

In Amirah’s medical notes Ms Boswell queried whether she had jaundice and due to her being less than 24 hours old, she should have referred her to a paediatrician but did not, the inquest was told.

She told the coroner: “I had written down 'query jaundice' because of the colour of her face but on my check list, which asks whether clinical jaundice was present, I said no.”

An admin error on Ms Boswell’s part also failed to send out a community midwife the following day to check on Amirah which she said was an oversight and apologised.

The coroner heard that a day later Trowbridge midwife Susan Smith took a worried call from Mrs Akgul regarding the missed visit but she failed to log the conversation until six days later.

Mrs Akgul, 42 said: “When I spoke to her on the phone I said that the midwife did not turn up and I presumed they were busy. But I did say her jaundice had got worse and she was going orange. She told me I had nothing to worry about.

“If she had been referred and if she was in the hospital, they would have been able to do something when the haemorrhage happened.

“We feel as a family that Amirah was failed in those first few days.”

Amirah, who was born at the Royal United Hospital weighing 6lb 4oz, was rushed back to hospital after her parents woke to find blood around her nose and mouth. After being intubated at the RUH, she was transferred to the Paediatric Intensive Care Unit at Bristol Children’s Hospital.

Only hours later, Amirah continued to deteriorate and Mrs Akgul asked to hold her daughter in her final moments.

An investigation was launched by the RUH Trust into Amirah’s death and as part of the review, the court heard how more guidelines have been given to midwives to look at signs of jaundice before 24 hours and after.

The trust are also trialling a new piece of equipment, a transcutaneous bilirubinometer, to check for jaundice in new-born babies.

Mrs Akgul, who shares three daughters with her husband Mehmet, 32, added that since the inquest she hasn’t received any apology from the trust.

“The machine they are proposing to get will only see the level at a certain time but it has already been nine months so why haven’t they got it already,” she added

“If I could warn other mums, I would say if you have a worry, just go straight to the hospital. If they had kept her in or been referred, her death could have been prevented. I wish I hadn’t listened to them and just took her back.”

Dr Steven Jones, consultant paediatrician at the RUH told the coroner that after Amirah’s death, he looked into whether jaundice was linked to pulmonary haemorrhage but could not find a link. He did say that if she was referred for jaundice, doctors would have been able to act sooner to stop the haemorrhage which they couldn't find a cause for.

While outlining a narrative verdict, Ms Voisin said staff at the birthing centre “had missed opportunities for Amirah to be reviewed and referred to a paediatrician”.

She added: “I find based on the evidence, that Amirah probably had jaundice and she should have been referred. She suffered a pulmonary haemorrhage at home but if it had occurred at hospital, she would have had a better chance of survival.

“Coroners have a duty to produce a report into a death to prevent further tragedies happening. But I must say, I have been mindful while hearing the evidence and I am told that the hospital is trialling a transcutaneous billirubinmoter with the view to secure funding to be able to purchase this equipment so I will not be making a report at this time.”

Helen Blanchard, Director of Nursing and Midwifery at the RUH, has said on behalf of the RUH Trust: “We once again extend our deepest condolences to baby Amirah Akgul’s family at this difficult time.

“The hospital has learnt from this sad event and the coroner has not ordered the trust to take any further action.”