A FOUR-DAY old baby’s death following an emergency caesarean birth at Gwent’s major hospital was from natural causes, a coroner has found.

An inquest had heard how the baby’s mother, Ceri Lewis, felt “ignored” by midwives after reporting severe pain and vomiting after attending at the Grange University Hospital, in Cwmbran, for an induced birth.

Her care had been consultant led as her pregnancy was judged high risk due to her having type two diabetes and having previously suffered two miscarriages.

Her son Jac Arthur Lewis, had to be twice resuscitated after he was delivered at 9.29pm on November 1, 2024 and treated in intensive care.

Gwent area coroner Rose Farmer said he died at the hospital on November 5 from a perinatal asphyxia, which is a lack of oxygen to the brain, in a baby with a small placenta.

After hearing more than two days of evidence Ms Farmer said it wasn’t her role “to decide whether care or treatment could have been improved” but to consider whether there were “clinical incidents” that required steps to be taken, and if they weren’t.

She said she didn’t find any “acts or omissions” that contributed to Jac’s death and said: “Even if I had I would not be satisfied that causation could be established”.

She said the evidence of consultant paediatric pathologist Dr Andrew Richard Bamber was the cause of the lack of oxygen couldn’t be known but the “very small placenta” had “little reserve” to “cope with additional stress” and was a “significant contributory factor in Jac’s death.”

When delivering her conclusion the coroner also said she had found Mrs Lewis wasn’t in labour during the appointment.

Ms Farmer also said she accepted the evidence of the midwife who was leading Ms Lewis’ care when she attended at the hospital, at 11.30am on November 1, that she hadn’t been aware Mrs Lewis had vomited. In evidence the midwife explained what actions she would have taken had she been aware of vomiting during an induction.

A second midwife, who was leading care during the evening shift, had responded after Mrs Lewis reported vomiting and Ms Farmer said she accepted why the midwife had taken a decision to try and manage the mother’s pain before listening for the baby’s heartbeat during an examination shortly before 8pm.

Mrs Lewis was rushed into theatre for the caesarean when the midwife checked for the baby’s heartbeat at 9.13pm.

The coroner said both midwives had made clinical judgements and their responses to Mrs Lewis reports of pain had been documented with observations and Ms Farmer said she didn’t find the pain was “clinically significant” and both midwives considered it “consistent with induction”.

She also said it was “appropriate” for the second midwife to have asked Ms Lewis to monitor her baby’s movements for 10 minutes after she had reported being in so much pain she wouldn’t know whether or not her baby was moving.

Ms Farmer also said she didn’t feel she should issue a prevention of future deaths report as she was satisfied with steps taken by the Aneurin Bevan Health Board, following its serious incident report, that include monitoring for a baby’s heart rate during induction in high risk pregnancies every six hours rather than 12.

The coroner said she accepted the difficulties in recalling events by Jac’s parents Mrs Lewis and husband Matthew, “at a time of stress” and while she noted records completed by midwives weren’t all written at the time accepted that hadn’t always been possible.