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A midwife who treated a mother-to-be as she experienced "distressing" pain was told not to mention an incident the night before in a statement to investigators after the baby died, an inquest has heard.
Amelia Amber Sweetpea Clyde-Smith suffered brain damage and died in September 2018 – just 33 days after she was born.
Her death and the events preceding it prompted an investigation and apology from the Health Department in 2019, but her parents, Ewelina and Dominic, continued to seek answers.
This week, an inquest will aim to establish exactly how Amelia came by her death.
The inquest, which opened this morning at International House, heard that Mrs Clyde-Smith had experienced a normal pregnancy until her waters broke around a fortnight before her due date, prompting her to go to the Hospital with her husband Dominic.
Pictured: The inquest opened this morning at International House, and is expected to run until Friday.
Staff initiated the process of inducing Mrs Clyde-Smith into labour on the afternoon she was admitted, however she told the inquest that she had experienced increasing levels of pain during the following night.
Although she had been told by staff at around midnight that she was not likely to go into labour for 24 hours, this actually happened within a few hours, by which time she was doubled-up with "horrific" pain.
Midwife Tambu Muoni, who had worked in the maternity unit at the General Hospital for 11 years at the time, gave evidence about the night shift she had worked on Saturday 18 August, when mother-to-be Ewelina Clyde-Smith was in her care.
Ms Muoni said: "I don't think I have seen that level of pain, ever, it was distressing and horrible."
Attempts to administer an epidural injection were initially unsuccessful as a result of the strong contractions Mrs Clyde-Smith was experiencing, but the injection was eventually given after her husband helped restrain her.
The inquest heard that Ms Muoni and other staff in the labour ward did not escalate the treatment of Mrs Clyde-Smith.
Baby Amelia, who suffered suspected brain damage, had to be transferred by air around 10 hours after being delivered to receive specialist care in the south of England.
Eventually the couple were told that no more could be done for their daughter and decided to bring her back to Jersey for a short period before she died.
Mrs Clyde-Smith said she had outlined a series of concerns regarding her care in a letter to the Deputy Viscount, including not being seen by a doctor, going long periods without care from a midwife, the failure of staff to act on high readings from the cardiotocography scanner – which measured Amelia's heart rate – and the failure to keep the placenta for analysis.
"It felt like no-one had Amelia's best interests at heart that night," she said.
Amelia’s death led to an investigation by the Royal College of Obstetricians and Gynaecologists, who found that there were "missed opportunities with management of maternal observations" after complications with the birth were recognised and that there was "an absence of a proper escalation policy" once things started to go wrong.
The inquest heard that there had been difficulties on the labour ward on the night before Mrs Clyde-Smith was admitted to the Hospital.
Details were not given, but Ms Muoni said that members of the night shift team had been shocked by what had happened, and that a manager asked her not to mention the incident in her initial statement to investigators.
The Chief Nurse and Medical Director at the time wrote to Mr and Mrs Clyde-Smith following the Royal College review in 2019 to offer an apology.
They said that they could not say whether her death was "inevitable", but added that, "we probably could have avoided it, and for that we are deeply sorry".
The inquest continues tomorrow.
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