Dr and Mrs Gonzalez are concerned that lessons should be learnt from the tragic death of their daughter

Solicitor Paul Balen

When the baby was born on 12 December last year, she initially appeared healthy.

The inquest heard that the hospital had downgraded its paediatric services in April 1998, and there was no longer doctor available to back up the verdict of the midwife on duty.

Signs missed

By the time Mrs Gonzalez was discharged eight hours later, her parents were told she had signs of jaundice.

However further home visits by midwives and the family's GP failed to detect the severity of the illness.

Three days later Mrs Gonzalez was advised to return her daughter to Grantham Hospital for blood tests and possible treatment.

Olivia's parents are calling for a public inquiry into Grantham Hospital

Dr and Mrs Gonzalez were then told to take Olivia for specialist care at Lincoln County Hospital, a two-hour journey away.

Tests at Lincoln showed the baby's level of bilirubin, the pigment which causes jaundice, was 700. The normal count should be nearer 30.

Despite a blood transfusion Olivia died the next day, of kernicterus, a staining of the brain caused by a high level of jaundice.

Accidental death

Consultant paediatrician Dr Robert Groggins, who treated Olivia at the County Hospital, told the inquest she would probably still be alive if the illness had been detected just 24 hours previously.

Recording a verdict of accidental death, Lincoln Coroner Roger Atkinson said he had considered adding that Olivia's death had been contributed to by neglect, but decided against it in this case.

But he discounted the lesser option of death by natural causes.

Paul Balen, solicitor for Dr and Mrs Gonzalez, said the couple believed there should be a public inquiry into the provision, running and monitoring of maternity and paediatric services at Grantham Hospital.

On behalf of the trust I would like to say how very sad we are at the death of Olivia

Sarah Skelton Lincolnshire NHS Trust

"If the public inquiry leads to the saving of any more life, then the death of Olivia Louise Gonzalez would not have been in vain."

Sarah Skelton, director of nursing and midwifery at United Lincolnshire Hospitals NHS Trust, said: "We welcome the coroner's comments that Mrs Gonzalez and Olivia had been treated by suitably qualified and experienced midwives

"He accepted their evidence that a full examination of the baby had been undertaken by two midwives on separate occasions shortly after delivery, and they had concluded there was no jaundice present.

She added: "The individual staff involved have already expressed their condolences to the family but on behalf of the trust I would like to say how very sad we are at the death of Olivia."