**Severe Failings in Medical Care Contributed to Death of Newborn at Bangor Hospital, Coroner Finds**
A coroner has raised serious concerns over the death of a newborn at Ysbyty Gwynedd, Bangor, after concluding that significant lapses in care and neglect played a contributory role in the tragedy. The findings were detailed at the conclusion of an inquest into the death of baby Etta-Lili Stockwell-Parry, who died in July 2023, only a few days after her birth. The case has prompted a formal Prevention of Future Deaths (PFD) report issued to Betsi Cadwaladr University Health Board (BCUHB), urging swift remedial action.
Etta-Lili’s mother, Laura Stockwell-Parry, was induced at the hospital and the baby was born on 3 July 2023 in a concerning condition. Medical examinations determined that Etta-Lili suffered from oxygen starvation—a diagnosis confirmed by a pathologist. Despite being transferred to Arrowe Park Hospital in Wirral in a bid to save her life, the infant sadly passed away four days later.
The senior coroner for north west Wales, Kate Robertson, presided over the two-day inquest held in Caernarfon. In her summing up, she highlighted a series of missed opportunities and procedural failings that, in her view, constituted neglect and “gross failures” in medical care. “There were several clear failures to identify and respond to warning signs throughout Laura Stockwell-Parry’s care,” Ms Robertson stated.
The inquest heard that warning indicators—most notably the lack of growth in the unborn baby around the 40-week mark—were not identified either by a community midwife or by staff on the maternity unit. Had these been noticed earlier, intervention before birth may have been possible. The coroner was also critical of the approach taken on 2 July, when staff at the midwifery-led unit allegedly failed to undertake holistic assessments and did not conduct necessary manual checks that could have flagged the baby’s distress.
Further compounding the situation, the coroner revealed that Ms Stockwell-Parry was induced and placed under only intermittent monitoring, rather than being referred to the labour ward for closer observation. There was also reported confusion between the recording of the mother’s pulse versus the fetal heart rate, as well as deficiencies in the documentation of vital signs.
Mrs Robertson said she was deeply concerned that systemic failures extended to the review process itself. According to the inquest, the subsequent neonatal investigation did not obtain statements from the clinicians involved in the newborn’s resuscitation, nor did it meet with them to explore the sequence of events. She emphasised that inadequate fact-finding could hinder institutional learning and efforts to prevent similar tragedies in the future.
Given these findings, the coroner issued a Prevention of Future Deaths notice to BCUHB, mandating the health board to provide, within 56 days, a detailed plan outlining steps to address each of the shortcomings identified.
BCUHB’s response, delivered by Angela Wood, Executive Director of Nursing and Midwifery Services, included an apology to the family and assurance of remedial actions. “We extend our deepest sympathies and condolences to the Stockwell-Parry family following the loss of baby Etta. We recognise the profound impact this has had on the family and are truly sorry,” she said. Ms Wood also stated that “significant steps” have already been taken to review, learn from and implement changes in training and clinical oversight within the Trust’s maternity services.
The health board has maintained that this was an “isolated incident,” but the coroner’s report makes clear there are important lessons that must be rapidly internalised and acted upon. There is hope that the heightened scrutiny and mandatory changes will help restore public confidence in local maternity care, and guard against a recurrence of similar tragic events.
This case has cast a spotlight on the vital importance of diligence, communication and protocol adherence within maternity services, and serves as a sobering reminder of the stakes involved. Many in the community will await BCUHB’s concrete plan and progress with keen interest, anxious to see improved safety and accountability for all families seeking care in North Wales health facilities.