The parents of a baby who died following neglect by maternity staff at Queen’s Hospital said the pain of hearing that their son could have been saved is “overwhelming”.
Zachariah Orefuwa Millin suffered a brain injury during his birth on October 26, 2024, and died aged six days.
An inquest heard that multiple failures by staff led to a delay in Zachariah being delivered by emergency caesarean section after a complication in which he became separated from the placenta.
When Zachariah’s mum phoned the hospital with a range of concerning symptoms, the handler recorded in her notes that she needed to attend hospital immediately but failed to convey this to her.
This led to her arriving at hospital 50 minutes later than she could have.
After the mum arrived at hospital, east London area coroner Nadia Persaud said there were “multiple missed opportunities” to escalate concerns to senior doctors.
This was despite her being assessed as having a modified early warning score (MEWS) of seven, which indicates that a patient is acutely ill and needs critical care.
Without these “gross failures”, Zachariah would have been delivered earlier and his death would have been avoided, Ms Persaud concluded on the balance of probabilities.
On Wednesday (June 17), Ms Persaud recorded that Zachariah died of natural causes contributed to by neglect.
Zachariah’s mum said: “The pain of hearing how different actions by maternity staff could have saved Zachariah is overwhelming. We have relived every terrible moment, minute by minute during the inquest.
“We are immensely private, but I make this comment in the hope of supporting other Black and Asian women who are dismissed or treated inappropriately by hospital staff.
“It is a pain that no family should have to endure, and we hope that the learnings taken from what happened to Zachariah will ensure better outcomes for other babies.
“Meanwhile, we treasure the precious moments we had with our baby. Our hearts ache every day, and he will forever be remembered as our perfect baby boy.”
A Maternity and Newborn Safety Investigation report -seen by this paper - says the mother felt her care was impacted by her ethnicity and that her and the father experienced "microaggressions".
The report says her increased pain was not considered an additional risk factor, adding: "Disparities in recognising and managing pain based on ethnic backgrounds are well documented."
Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) has apologised and admitted the standard of care at Queen's Hospital did not meet the standard.
Nic Kane, chief nurse, said: “We’re sorry we failed Zachariah and his family and caused them so much pain and distress.
“When a baby dies in our care, we are determined to listen to the parents, learn from our mistakes and improve.
“We’ve increased staffing levels in our triage department (including having an obstetric doctor and senior midwife available at all times); our training in pain management and how to monitor a baby’s heart rate and a mother’s contractions have been made more robust; and we’ve extended pre-eclampsia testing to ensure women with an increased risk are closely monitored.”
Zachariah is one of three babies born in September and October 2024 whose deaths have been examined in inquests amid concerns that failures in treatment at Queen’s Hospital contributed to their deaths.
Ms Persaud ruled in January that the death of baby Ada Rose was preventable, and the trust apologised for the standard of care it provided.
Tomorrow (June 18) the coroner will announce her findings in the inquest of George Delaney, who died two days after he was born at hospital in September 2024.
Punam Sood, representing Zachariah’s family on behalf of Fieldfisher law firm, said: “We hugely appreciate that the coroner is doing everything she can to effect change to keep babies and their mothers safe in our hospitals by ensuring a thorough investigation of what happened.
“We also acknowledge that the trust has implemented systemic and practical changes, not least by highlighting cultural sensitivity around how women are listened to by staff.
“Ultimately, though, communication between staff and the systems in place at that time were not good enough to deal with the level of care needed on that night and an emergency situation that was evolving, but went unnoticed.
“On behalf of all the families we represent who live the tragedy of losing a baby, we sincerely hope that when it is published in two weeks, Baroness Amos' review has the strength to improve maternity care in this country.”
BHRUT is one of fourteen NHS trusts which has been probed in relation to its maternity services, against a backdrop of a major increase in maternity 'red flag' alerts at the hospital.
Since the national investigation, led by Baroness Valerie Amos, was announced in September 2025, the Care Quality Commission (CQC) has improved its rating of maternity services at Queen's.
Inspectors previously advised that maternity services required improvement following an assessment in October 2024, but have most recently amended this to a 'good' rating after a revisit in August 2025.
In relation to Zachariah’s death, Ms Persaud decided against issuing a prevention of future deaths report, noting the steps taken and the trust’s approach to learning from this tragedy.
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