The lawyer who represented the family of Eddie Coffey, a one-day-old baby who died at Lister Hospital in 2019, has spoken out about the Care Quality Commission's new "inadequate" rating for the maternity ward at the hospital.

An inquest in 2020 found that negligence on the part of the Lister Hospital contributed to Eddie's death.

It was found that during the delivery, the cardiotocograph (CTG) appeared to have recorded Eddie’s mother’s heart rate rather than Eddie’s, which may have meant Eddie would have survived.

Four years after Eddie's death, a CQC report gave Lister's maternity ward an "inadequate" rating - the lowest possible - and found continuing issues with CTGs on the ward.


At the time of the CQC's inspection, midwives were 95 per cent compliant with the annual training on CTG interpretation and categorisation, consultant obstetricians were 81 per cent compliant, and trainee medical staff were 88 per cent compliant. The East and North Hertfordshire NHS Trust has a target of 100 per cent compliance.

The report also found that one CTG machine had not been serviced since April 2019, and "staff described a shortage of equipment including CTG machines".

The CQC inspectors "saw three incidents were there was no available CTG machines for women which resulted in delays in providing safe care".

Tim Deeming, of Tees Law, acted for Eddie's family after his death. Following the CQC's report, he said: “It is deeply concerning that Lister Hospital has been further downgraded for maternity services four years after Eddie’s tragic death.

“In 2020, the Coroner determined on all of the evidence that it was neglect to fail to provide such basic care to Eddie and that alternative management may have avoided such a tragic outcome.

"The Coroner was not reassured that the same situation would be avoided in future and submitted a Prevention of Future Deaths report.

"Unfortunately, it seems that some areas have not improved since then, with training standards 12 per cent below the Trust’s target.

“We know that there are national staffing concerns, but it is crucial that the hospital now learns lessons throughout and implements them.

"Improvements suggested at a national level following the Ockenden investigations need to be fully carried out so that there are no regional variations or gaps.

“It is heartening to know that the director of midwifery has an action plan and we hope that all concerns can be fully addressed so that the CQC can see evidence of improvement in its next review.”

At the time of the inquest, Eddie’s mother, Hannah Coffey, said, “Saying goodbye to our beautiful boy only hours after he had been born left us all with a hole in our hearts from which we will never recover.

“Not for a moment did I imagine that we could arrive at hospital with a healthy baby and leave without him in our arms. Like many expectant parents we put our trust in the care we would receive.

“Knowing that a lack of competence in the use of vital medical equipment could affect other families in a similar way is driving us to raise awareness of the need to ensure proper training and use of equipment to help save the lives of other babies.”

Amanda Rowley, the new director of midwifery at East and North Hertfordshire NHS Trust, said: “We are deeply sorry for Eddie’s death in 2019 and recognise the additional distress the CQC report would have caused his parents.

“We take the findings in the report very seriously and are already working on the recommendations, as well as those of the Ockenden review.

“We have made immediate improvements to strengthen the safety of our services. This includes enhanced training for all maternity staff, including how we safely monitor and manage fetal heart rate during labour.

“I have already led immediate and thorough action to increase cleanliness, and to ensure equipment is up to the standard required and available to midwives across all birthing rooms, maternity and consultant led units.

"We have also recruited an additional 17 midwives during a period of national shortage – ensuring our staffing levels are in line with other maternity units in the East of England.”