Twin girls' deaths after birth preventable - coroner

Twin baby girls who both died with tangled umbilical cords shortly after birth could have survived if they had been delivered earlier the same day, a coroner says.

She also found that neglect played a part in the deaths of Alys Haf Jones and Efa Swyn Jones, who it was discovered had been sharing the same amniotic sack.

The babies were delivered by emergency caesareans section at Ysbyty Glan Clwyd in Bodelwyddan, Denbighshire, on the afternoon of 15 July, 2022.

Betsi Cadwaladr University Health Board (BCUHB) said it accepted the coroner's findings and would "take all action possible" to improve.

The inquest at Ruthin heard how their mother Glian Llwyd Jones, from Llansannan in Conwy county, had had a scan that morning at 29 weeks gestation, which revealed reduced blood flow to one of the babies, and was referred to the maternity assessment outpatient unit at the hospital for monitoring.

But following an hour of monitoring, which concluded further investigation was required Ms Jones, who had also tested positive for Covid, was allowed to go home to get some belongings, before resuming monitoring back at the unit two hours later.

Forty minutes after that, when one of the twins' heart rates could not be detected, she was taken for the emergency delivery.  

But it was discovered the babies’ cords were knotted and tangled together and they could not be resuscitated.

The hearing was told how Ms Jones had been made aware that her babies might be in the same amniotic sack, after early pregnancy scans, but that she was later told that there was a membrane present between the two babies.

In her statement read to the court, Ms Jones said that after her babies were born, she was told there had in fact been no dividing membrane, allowing the cords to become entwined.

She said it made her “angry” because “from the start, they had not been sure if it was there or not”, and it was “something she was worried about.”

She went on to say BCUHB later told her and her husband at a meeting that “things should have been done differently” and that “more tests should have been carried out, to see if there was a dividing membrane or not”.

The assistant coroner for north Wales east and central, Kate Robertson, said there had been a “gross failure” to provide appropriate medical care for the mother and her babies, and there was a clear link between that and their deaths, which had been “avoidable”.

She added that the initial monitoring at the maternity assessment unit on 15 July should not have been paused and that Ms Jones, who had not been made fully aware of the seriousness of the situation, should not have been allowed to go home.

"There were gross failures in medical care," she said.

"Alys and Eva’s deaths were contributed to by neglect."

The coroner said she would not be making a prevention of future deaths report due to evidence she heard that change and learning had taken place at the health board, and that she had been "provided with reassurance that there will be more learning".

The medical cause of the babies’ deaths was recorded as perinatal brain injury.

The BCUHB chief executive, Carol Shillabeer, said: "I offer my heartfelt condolences to the family for the tragic loss of their twin babies.

"It is clear that the health board failed to provide the standard of care that should be expected, for which we are truly sorry," she added.

"We fully accept the coroner's findings, and are determined to take all action possible to improve our care.

"This improvement is already underway and we will look again at any further action we can take."