At an inquest hearing held on 19 and 20 May 2025 at Gwynedd Coroners Court, HM Senior Coroner Kate Robertson said it was “one of the most troubling cases” she had dealt with. The Coroner found that Etta’s death, at just four days old, could have been avoided with proper medical care, and concluded that it was contributed to by neglect.
Laura Stockwell-Parry became pregnant with Etta in October 2022. Her pregnancy was not considered high-risk and was managed by community midwives. However, concerns about Etta’s growth were missed on two occasions during antenatal appointments – once at 40 weeks and 1 day, and again at 40 weeks and 5 days – with no referral made for an obstetric review.
On 2 July 2023, Laura and her husband Tristan attended Ysbyty Gwynedd for an induction of labour, believing all was well with the pregnancy. Midwives again failed to recognise that Etta’s growth had stopped, and Laura was not transferred to the Labour Ward for continuous monitoring, as she should have been. Instead, she remained on the maternity-led unit.
Laura was only moved to the Labour Ward at 00:02 on 3 July due to slow labour progression. A CTG monitor was started at 00:08 to check the baby’s heart rate, but staff did not take Laura’s pulse beforehand – a critical step needed to ensure the CTG was monitoring the baby and not the mother.
Etta was born at 00:51 in very poor condition. She required immediate resuscitation and was taken to the Special Care Baby Unit. Due to the severity of her condition, she was transferred later that morning to Arrowe Park Hospital for specialist treatment.
By 7 July 2023, it was determined that Etta had suffered a severe hypoxic brain injury – Hypoxic-Ischaemic Encephalopathy Grade 3 – due to a lack of oxygen. Her life support was withdrawn, and she passed away peacefully in her mother’s arms.
The Coroner found that there had been gross failures in basic care, including missed opportunities to identify that Etta had stopped growing and to detect that the CTG was monitoring Laura’s heart rate, not Etta’s. She concluded that had these issues been properly identified and acted upon, Etta would likely have been delivered earlier and would have survived.
The Coroner also raised serious concerns about the internal investigation conducted by Betsi Cadwaladr University Health Board. She found it unsatisfactory and noted that learnings had not been properly shared within the organisation. As a result, she issued a Prevention of Future Deaths Report and confirmed her intention to raise the matter directly with the Chief Executive of the Health Board.
While Tristan and Laura have welcomed the Coroner’s conclusion and her decision to issue a Prevention of Future Deaths Report, they remain heartbroken by the finding that, with appropriate basic care, Etta would likely have survived and still be with them today. They are also deeply dissatisfied with the internal investigation conducted by the Health Board, and are determined that meaningful action is taken to ensure other families are not forced to endure a similar tragedy.
Following the inquest, Etta’s parents said:
“We went into hospital on the morning of the 2nd of July 2023, excited to become parents and meet our baby girl. Instead, our whole world was turned upside down.
The inquest into Etta’s death has left us heartbroken all over again. We were devastated to learn that numerous opportunities to safely deliver our beautiful baby girl were missed. Although we knew of the numerous failings in care that were identified by the hospital in their SI Report, we hadn’t realised the gravity of the basic failures in our care.
We are extremely grateful to the Coroner for her thorough investigation and her conclusion that Etta’s death was contributed by neglect as a result of gross failures in basic medical care. We are also grateful that she shares our concern in the Health Board’s investigation and learning processes. None of this can bring Etta back to us, but we want to ensure that no other family goes through the heartbreak of losing their baby unnecessarily.”
The family were represented by Elen Hawkley, Solicitor in our Clinical Negligence Department, and by counsel Nia Frobisher of 7BR at the inquest.
Elen Hawkley said:
“Laura and Tristan attended Ysbyty Gwynedd on 2 July 2023 full of hope and excitement to meet baby Etta. There was no indication that anything was wrong, and throughout labour, Laura was reassured that all was going well.
However, instead of joyfully welcoming baby Etta into the world and enjoying their first moments together, they witnessed their baby being taken away to be resuscitated, with no understanding of what had gone wrong.
While isolated signs such as static growth or maternal heart rate being recorded on a CTG can sometimes occur for various reasons, in this case, there was a complete failure to recognise and act on these critical red flags.
Sadly, this failure had devastating and heartbreaking consequences for baby Etta and her parents, who were so badly let down.”
