"Confirmation bias" a factor in the death of a Worksop baby, coroner rules

Clay Wankiewicz died at the hospital in July 2020 from skull fractures caused by the use of forceps and problems releasing his head from his mother's pelvis, an inquest found.

A new report has said medics failed to consider alternative birthing methods and be open to altering their approach.

Confirmation bias - which sees information favoured which is already believed - led to Clay's mother, Beth Wankiewicz, being encouraged to continue pushing for two hours in attempts to give birth, according to senior coroner Nicola Mundy.

After trying unsuccessfully to deliver Clay with forceps, he was born by Caesarean section. He died 22 minutes later, despite resuscitation efforts.

In a report aimed at preventing future such deaths, Ms Mundy said: “I found there had been a failure to attach sufficient weight to factors which should have called into question the appropriateness of advice encouraging any continuation of the efforts to push and a failure to engage obstetric input at an earlier stage.

“The trust accepted that there had been confirmation bias in this case.”

She said steps had been taken in response to this by the trust, but some staff giving evidence during the inquest failed to “appreciate the meaning and significance of confirmation bias, and the importance of being open minded.”

The report added: “If the obstetric staff do not change their practices to ensure that confirmation bias is no longer a feature in any care provided there is a significant risk that situations such as this will continue to occur in the future.”

Responding to the report Clay’s parents, Daniel and Beth, said: “We truly believe that had the trust provided better care, he would be here today.

“Clay Bear will be so sadly missed, with his Wreck-It Ralph hands and his perfect cheeks, and he was perfect.

"We feel at such a loss that he is not with us. We are grateful to the coroner for her observations and that we did everything that we could to protect our precious son."

They added: “We are deeply concerned with the evidence of the trust of changes they propose to make and feel far too little has been done in the 13 months since Clay has died.

"They don’t appear to accept their failings or make real steps to protect other babies."

The couple added the were “grateful” to the coroner for the steps she has taken to “ensure that the trust makes real change”.

Doncaster and Bassetlaw NHS Trust offered its "deepest sympathies" to Clay's family.

David Purdue, the trust's chief nurse and deputy chief executive, said: "Following Clay’s very sad passing, the trust made a referral to the Healthcare Safety Investigation Branch, who started an investigation into the care provided and their findings were shared with the relevant teams at the trust, Clay’s family and Her Majesty’s Coroner.

“The provision and delivery of high quality maternity care is our number one priority and we try to ensure that lessons are learnt and services improve.

"On receipt of the report, necessary plans, actions and training were put in place, working within the appropriate guidance, as well as respecting the wishes of our parents.”