Newborn baby was wrongly pronounced dead while she was still alive by a paramedic and wrapped up in towels before dying without treatment 15 minutes later

• Alison Davis was wrongly sent home to suffer a traumatic miscarriage
• Her baby was then pronounced dead and left in the ambulance
• Midwife then noticed she was alive but she died before seeing her parents
• Coroner slams 'gross failure in the management' of the situation

A premature baby wrongly pronounced dead by paramedics lived on for more than 15 minutes wrapped in towels on the front seat of an ambulance.
A coroner criticised a doctor’s ‘gross failure’ in not examining Alison Davis, who was in severe pain, before sending her home to Eastwood, Essex, to a traumatic miscarriage.
Paramedics then wrongly pronounced baby Bethany Davis dead when her mother gave birth an hour later.

'Traumatic sequence of events': Alison and Glen Davis (centre pair) stand with Alison's father Trevor Webber and sister Adalena Webber outside Southend Coroners' Court

After rushing Mrs Davis to hospital, they left the baby on the front seat of their ambulance for more than 15 minutes while treating the distraught mother.
A midwife then spotted the infant was alive, an inquest into the child’s death at Southend Coroners’ Court heard; but by the time she was reunited with her mother she had died as a result of her prematurity.
When Mrs Davis gave birth to Bethany on her parents toilet, her family endured six 'terrible' minutes that 'felt like a lifetime' as an 'overwhelmed' paramedic waited for back up.

Traumatic: Mr Davis, Mrs Davis and Georgina Davis, 14, hold casts of Bethany's hands and feet

That paramedic, described by Mrs Davis's father Trevor Webber as like 'a rabbit in the headlights', 'regressed' to training that a baby born earlier than 24 weeks was not viable.
He refused to move Mrs Davis or Bethany or cut the umbilical cord before the ambulance arrived in case he risked harming her.
Mr Webber said: 'It was terrible. Those six minutes felt like a lifetime.'
On arrival, the ambulance crew wrongly pronounced Bethany dead, wrapped her in towels and put her on the front seat as they took Mrs Davis back to Southend University Hospital in Essex.
They failed to ask Bethany's father, Glen, if he wanted to hold her, as protocol demands. They took Mrs Davis into hospital on a trolley, leaving the infant on the front seat for 10 to 15 minutes.
When the crew finally handed over Bethany, a midwife noticed she had a heartbeat and was moving her fingers. But the baby had died before she was taken to her parents, who never saw her alive.
Mrs Davis, 33, said: 'We were robbed of the precious time with her alive.

'It’s the hardest thing as a mother, knowing she was in another room and if she could have called out "Mummy come and get me", she would have done'

Alison Davis

'It’s the hardest thing as a mother, knowing she was in another room and if she could have called out "Mummy come and get me", she would have done.'
Registrar Dr Oludare Adeyemi failed to follow protocol and give Mrs Davis an internal exam after she reported excruciating pain in her abdomen, thighs and back, the baby kicking at a low position, bleeding and discharge on December 12, 2009.
He instead relied on an inadequate examination by trainee Dr Uzoamaka Odina, who was only 10 days into the job, before diagnosing a threatened miscarriage and discharging Mrs Davis.
No midwife was present when Dr Odina examined Mrs Davis, as hospital policy demands.
'It’s a gross failure in the management of this very traumatic situation,' said Coroner Dr Peter Dean.
'The protocol wasn’t adhered to and as we have heard from the very frank and clear evidence, had things been managed according to the protocol it’s clear Alison Davis would have stayed in hospital.
'The outcome is unlikely to have been different had she stayed in hospital.
'But it’s undeniably the case if she had been kept in hospital she would have avoided the traumatic sequence of events that took place in the next few hours at home.
'It’s clear the family went through an awful sequence of events on arriving home and one can only hope the pain of those awful events will diminish over time.'
Recording a narrative verdict, Dr Dean said Bethany died as a result of her premature birth.

'A gross failure in management': Coroner Dr Peter Dean criticised staff at Southend University Hospital, where Mrs Davis was treated

Jacqueline Totterdell, chief executive of Southend University Hospital, said: 'We again offer our sincerest condolences to Mrs and Mr Davis for the loss of their baby and the distress they have suffered.
'While staying in hospital would not have altered the outcome for Bethany because of her extreme prematurity, we recognise that if our protocol for women presenting with a persistent or recurrent bleed to be examined by senior staff had been followed correctly, the family would not have suffered the loss of their daughter in such a distressing way without the immediate support of medical staff and our bereavement counsellors.
'Since Bethany’s death in 2009 we have taken a number of steps to address the concerns this tragic case raised including better support and guidance for junior staff from senior colleagues, improved training on our guidelines and policies and increased awareness of the need for a good standard of note keeping and communication between doctors and midwives.
'We have also updated guidelines around caring for very early term births to include better support and counselling for mothers at risk of delivering extremely pre-term babies.
'We accept the standard of care the Davis family received at that time was not of the highest we would expect, and have listened carefully to the coroner’s comments and will ensure they are fully acted upon.
'We once again extend our sincere apologies to Mr and Mrs Davis and family for our shortcomings in this very sad case.'