Twin girls’ deaths soon after birth preventable – coroner

Twin baby girls who both died with tangled umbilical cords shortly after birth could have survived if they had been delivered earlier the same day, a coroner says.

She also found that neglect played a part in the deaths of Alys Haf Jones and Efa Swyn Jones, who it was discovered had been sharing the same amniotic sack.

The babies were delivered by emergency caesareans section at Ysbyty Glan Clwyd in Bodelwyddan, Denbighshire, on the afternoon of 15 July, 2022.

Betsi Cadwaladr University Health Board (BCUHB) has been asked to comment.

The inquest at Ruthin heard how their mother Glian Llwyd Jones, from Llansannan in Conwy county, had had a scan that morning at 29 weeks gestation, which revealed reduced blood flow to one of the babies, and was referred to the maternity assessment outpatient unit at the hospital for monitoring.

But following an hour of monitoring, which concluded further investigation was required Ms Jones, who had also tested positive for Covid, was allowed to go home to get some belongings, before resuming monitoring back at the unit two hours later.

Forty minutes after that, when one of the twins’ heart rates could not be detected, she was taken for the emergency delivery.  

But it was discovered the babies’ cords were knotted and tangled together and they could not be resuscitated.

The hearing was told how Ms Jones had been made aware that her babies might be in the same amniotic sack, after early pregnancy scans, but that she was later told that there was a membrane present between the two babies.

In her statement read to the court, Ms Jones said that after her babies were born, she was told there had in fact been no dividing membrane, allowing the cords to become entwined.

She said it made her “angry” because “from the start, they had not been sure if it was there or not”, and it was “something she was worried about.”