EVIDENCE of “substandard care” and a lack of communication has been given by a hospital consultant at an inquest into the death of baby Henry Maw, who died at birth 14 years ago.

Paul Ballard, consultant obstetrician at Northallerton’s Friarage Hospital in 2005, eventually carried out a caesarean section on Henry’s mum June Hewson. He told the inquest at Northallerton he believed it was possible the baby's life could have been saved if alarm bells had been rung earlier.

Ms Hewson had been in “excruciating pain” for hours after being given medication to induce the baby, but medical staff failed to realise she was rupturing although this was a rare possibility. When concern was raised it wasn’t passed onto staff in the delivery room.

Ms Hewson, 46, of Bullamoor Road, Northallerton, had had two children, one born by caesarean and a later natural birth but with complications and after five miscarriages before the pregnancy with Henry, believed she was a high risk patient.

On August 22, 2005 she was given the induction medication at 6.40am. Henry was born at 7.43pm that evening but was pronounced dead after 50 minutes of attempted resuscitation failed.

Mr Ballard said the first time he saw Ms Hewson at about 6.40pm he was shocked to see how much pain she was in, adding: “She was climbing up the wall.” He said he was 99 per cent certain she was rupturing and organised a caesarian, but the theatre was busy and it took 63 minutes before Henry was born.

He said: “I think there were a number of elements of sub standard care. The concerns the midwife had were not properly communicated.”

Assistant Coroner John Broadbridge asked if opportunities to save Henry had been missed.

Mr Ballard said they had. He said ruptures were rare – he had only experienced two others in his career – but added: “We should all know continuous pain following induction and the presence of a scar should send alarm bells.”

Mr Broadbridge asked if there was a culture of staff fearing to report. Mr Ballard responded: "There have been those cultures, I think to some extent that culture still exists. Staff should report mistakes and if you don’t have that culture, everyone suffers.”

The inquest also heard evidence from independent obstetrics expert Emma Ferrimen, who prepared a report for the National Crime Agency after the case was reported to the police before being referred to the Coroner. She said there were two opportunities to save the baby's life, between 3pm to 4pm when the rupture started when there was a good chance he could have been born alive and well, and if he had been born more quickly after 6.50pm it was likely he would have been alive but with problems. “I would agree with the family that this was an unexpected avoidable death,” she added.

She said she believed Henry was stillborn although one of the doctors trying to resuscitate him told the hearing she heard some heartbeats.

The inquest continues.