The inquest into the death of Casey Garrett, seven hours after his birth at Bedford Hospital, concluded on 21 July 2015.

Senior Coroner Thomas Osborne delivered a narrative verdict, concluding: “Casey Garrett was born on 10 September 2014. Prior to his delivery at Bedford Hospital there were a number of failures to recognise that his condition was deteriorating and there was a failure to escalate the levels of care so as to expedite his delivery. These failures resulted in a lost opportunity to deliver him earlier and avoid his death. He died on 11 September 2015 at 07:10 from perinatal asphyxia.”

The inquest examined the standard of care provided including the midwifery team’s ability to interpret foetal heart rates.    

Sebastian Naughton was instructed by Julie Say of Hodge Jones & Allen, who commented, “this has been one of the most open inquests that I have attended and one that has been a force for change with all interested parties working toward improving patient safety”.

The Coroner is to write a Prevention of Future Deaths letter to the body responsible for training student midwives, querying whether Bedford Hospital is an appropriate place to train students in the light of the series of failings the inquest identified.