‘But for failings in care we might be celebrating Jack’s fifth birthday’

Jack’s parents said that they had campaigned for truth and justice for all that time and ‘encountered resistance, every step of the way’.

But for the actions of a ‘brave whistle-blower’ none of the facts might have been learned. ‘The expert evidence recorded a litany of harrowing failures in midwifery, obstetric and paediatric care as well institutional failings in clinical care, management and governance, many of which were not explored given the court’s decision that it did not want to decide the facts or hear from witnesses who were there at the time Jack died,’ they said.

They said that whilst one expert had concluded in his report that all the failings, ‘in all probability, contributed in some way’ to Jack’s death, ‘because of the legal technicalities employed by the inquest, it has not been possible to directly attribute the failings in care to Jack’s cause of death’.

‘We will always feel those failings in care, whether individually or collectively, contributed to the loss of our beloved son.’

Mistakes by the midwives had already been reported, but expert evidence before the inquest identified others, they said.

Baby Jack’s parents maintain that this showed failings in care had caused trauma to their son and led to a haemorrhage.

They also say that medical staff failed to diagnose Jack’s condition, failed to seek help and failed to correctly intubate him three times.

‘Jack was deprived of oxygen for the first eight hours of his life. The expert evidence at the inquest confirmed that Jack’s condition could have been survivable had he received proper treatment.

‘None of the doctors admit these failings identified by their peers/experts,’ said the parents.

‘It is impossible to see how the public interest could be served, or health services improved, in the face of such arrogance.’

At the inquest, an expert also explained that UK hospitals are ranked as tertiary (being the most advanced), secondary and local (being the most basic).

In the opinion of that expert, the standard of neo natal emergency care in Guernsey falls below that of a local hospital in the UK, i.e. lower than the lowest standard of care in the UK.

One expert described the environment at the PEH in Guernsey at the time as “inherently dangerous”.

‘We can only hope that Guernsey’s politicians, senior health officials and individual clinicians take heed of Jack’s case and acknowledge the limitations in care on the island and implement better processes and procedures to ensure that complex medical situations can be managed with appropriate support and assistance from the larger/more experienced hospitals in the UK.

‘Such arrangements will foster better medical care and a safer culture for island families.

‘Indeed, as the evidence before the inquest found, had such arrangements been in place and/or used in Jack’s case, he could be alive today and celebrating his fifth birthday.’