Inquest Finds Maternity Failings at Queen’s Hospital — Havering 2026

Key Points

• An inquest found that baby Zachariah Orefuwa Millin suffered a brain injury during birth at Queen’s Hospital on 26 October 2024 and died at six days old.
• East London Area Coroner Nadia Persaud recorded neglect as a contributing factor while concluding the cause of death was natural.
• The inquest found delays and missed opportunities: a delayed emergency caesarean after concerns in labour, failure to communicate urgency when the mother first contacted the hospital, and missed escalation despite a high Modified Early Warning Score (MEWS).
• The family reported being devastated and urged lessons to be learned to prevent similar tragedies.
• The inquest raised concerns about inequalities in maternity care; the mother reported perceived microaggressions and that her ethnicity affected pain recognition and management.
• Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) accepted care fell below expected standards, apologised, and pledged to learn and implement improvements.
• The findings arrive amid wider scrutiny of maternity services in England and follow other local reports of problematic care and communication.
• The Care Quality Commission (CQC) has previously inspected BHRUT maternity services, noting staff commitment but identifying safety, leadership and risk-management weaknesses.

Romford (East London Times) June 19, 2026 – An inquest held at East London Coroner’s Court concluded that multiple missed opportunities and delays in care contributed to the circumstances surrounding the death of baby Zachariah Orefuwa Millin, who sustained a brain injury during his birth on 26 October 2024 and died aged six days, East London Area Coroner Nadia Persaud found.

As reported by (Nadia Persaud) of East London Coroner’s Court, the coroner delivered findings that recorded neglect as a contributing factor while determining the medical cause of death as natural. The inquest established a series of critical failures around communication, timeliness of intervention, and escalation of clinical concern.

What delays and missed opportunities did the inquest identify in Zachariah’s care?

As reported by (Local court transcripts) of East London Coroner’s Court, the inquest heard that Zachariah’s mother experienced concerning symptoms prior to admission but that the urgency of her condition was not adequately conveyed by initial contacts with Queen’s Hospital.

That delay in the pathway from first contact to arrival at hospital was found to have contributed to the subsequent chain of events.

As reported by (Coroner Nadia Persaud) of East London Coroner’s Court, the inquest further identified a delay in performing an emergency caesarean section after worrying signs emerged during labour.

The evidence presented showed there were missed opportunities to escalate the mother’s care to more senior medical staff, despite her high Modified Early Warning Score (MEWS), a tool used to detect clinical deterioration.

The coroner concluded these failures together contributed to the circumstances in which Zachariah suffered a brain injury during birth.

Who has spoken for the family and what did they say?

As reported by (family statements) to the inquest, Zachariah’s family described their devastation and the ongoing pain of losing their son. The mother told the court she hoped lessons would be learned and that changes in practice would help prevent other families experiencing similar heartbreak.

She also gave evidence that elements of her care were affected by how staff perceived her ethnicity, including experiences she described as microaggressions and a sense that her pain was not fully recognised as a risk factor.

What did the trust that runs Queen’s Hospital say about the findings?

As reported by (Barking, Havering and Redbridge University Hospitals NHS Trust) in a public statement, BHRUT acknowledged that the care provided fell below the standards expected and apologised to the family for failings identified by the inquest.

The trust said it was committed to learning from the circumstances surrounding Zachariah’s death and to implementing improvements to reduce the risk of similar incidents in the future.

How do these findings fit into wider concerns about maternity services locally and nationally?

As reported by (Care Quality Commission inspections) of BHRUT maternity services, the trust’s maternity units have previously been inspected with inspectors recognising staff commitment and professionalism while also flagging areas requiring improvement, notably around safety, leadership and risk management. The coroner’s findings in Zachariah’s case arrive amid heightened national attention on maternity and newborn safety following a number of high-profile investigations and reviews across England.

Are there other local incidents raising questions about maternity care at BHRUT?

As reported by (Havering Daily) journalist last week, a separate case from Rainham involved a mother who said she was repeatedly told she was experiencing a suspected miscarriage before later being informed her unborn baby had a strong heartbeat.

That mother described the emotional toll of being told on multiple occasions that she might have lost her baby and questioned aspects of the care she received.

While the circumstances differ and should not be directly compared, both cases have fed local debate about communication and safety in maternity services.

What evidence was presented about inequalities in maternity care?

As reported by (inquest witness statements) to East London Coroner’s Court, Zachariah’s mother raised concerns that her ethnicity played a role in how her symptoms and pain were interpreted.

The inquest referenced a wider report and national evidence which indicate disparities in maternity outcomes and pain management experienced by some women from ethnic minority backgrounds. Those findings formed part of the coroner’s consideration of contributory factors in the case.

What remedial steps has BHRUT said it will take?

As reported by (BHRUT communications) in the trust’s response, BHRUT has committed to reviewing the inquest findings and taking steps to improve maternity care, though the trust did not detail specific actions in the initial statement released after the hearing.

The trust reiterated its apology to the family and its commitment to implementing lessons learned to reduce future risks.

What did the coroner recommend, if anything?

As reported by (Coroner Nadia Persaud) during the inquest, the coroner’s narrative and findings highlighted systemic issues around communication and escalation. Coroners may direct local health bodies to consider prevention of future deaths (PFD) reports if they judge systemic failings could lead to similar outcomes; the coroner’s detailed conclusions emphasised the need for clearer processes for recognising and escalating deterioration, better triage communication, and attention to equity in clinical assessment.

Any formal PFD report would set out recommendations for action; at the time of the inquest’s conclusion, the coroner’s findings underlined those themes.

How are the family and local campaigners responding?

As reported by (family statements and local campaign groups) following the inquest, Zachariah’s family expressed a desire for meaningful change so other parents would not suffer the same loss.

Local campaigners and patient-safety advocates have used the case to call for stronger measures to address communication failings, earlier escalation of maternal deterioration, and tackling disparities experienced by women from minority ethnic backgrounds.

What scrutiny have regulators applied to BHRUT maternity services previously?

As reported by (CQC inspection reports) the Care Quality Commission’s earlier inspections recognised staff professionalism while identifying weaknesses around safety, leadership and risk management in BHRUT’s maternity services.

Those inspections prompted improvement actions and follow-up monitoring by regulators, and the coroner’s findings add fresh pressure on the trust to demonstrate sustained progress.

Why do families emphasise that reports and statistics are more than numbers?

As reported by (family testimony) at the inquest, the human impact behind statistics is stark: for Zachariah’s family, the inquest findings and wider reports translate into the loss of a much-loved baby boy.

Families said they hoped that public scrutiny and transparency would focus action on preventing future tragedies rather than only producing reports.

Background of the particular development

The inquest into Zachariah’s death follows a period of intense national scrutiny on maternity and neonatal safety in England. Over recent years, multiple high-profile investigations have examined systemic failings in maternity services, leading to inquiries, recommendations, and targeted regulatory interventions.

Barking, Havering and Redbridge University Hospitals NHS Trust runs Queen’s Hospital and King George Hospital and has been subject to Care Quality Commission inspections that acknowledged staff commitment while identifying areas needing improvement, particularly around safety leadership and risk management.

Local media reports have highlighted other concerning experiences — such as communication failures and misdiagnoses — which together underscore persistent challenges in maternity pathways, including triage, escalation, and culturally competent care. Coroners’ findings in individual cases can prompt Prevention of Future Deaths (PFD) reports, and organisational responses typically involve action plans, training, audit, and policy updates to address identified gaps.

Prediction: how this development can affect expectant mothers, families, and local services

• Expectant mothers and families: The inquest’s findings are likely to increase anxiety among expectant parents in the local area, prompting more questions about how concerns are triaged and escalated. Some families may seek additional reassurance through second opinions or choose to birth at alternative units where feasible. The focus on inequalities may encourage women from ethnic minority backgrounds to be more vocal about their care and to demand clearer communication and advocacy during clinical interactions.
• Local services and BHRUT: The trust will face renewed pressure from regulators, commissioners, and the public to demonstrate concrete improvements. This is likely to accelerate internal reviews of triage protocols, escalation procedures, MEWS training, and communication standards. The trust may need to publish detailed action plans, increase senior clinical oversight, and implement targeted training on recognising deterioration and on cultural competence.
• Regulators and policymakers: The case may prompt further local and national scrutiny of maternity safety metrics and could contribute to regulatory follow-up from the CQC. If a formal Prevention of Future Deaths report is issued, recommended changes might be required for the trust and potentially influence wider policy on maternal escalation pathways and equity in maternity care.
• Community trust and uptake of services: If families feel reassured by transparent, demonstrable improvements, trust in local maternity services could be restored over time. Conversely, failure to act visibly and effectively could lead to reduced confidence, higher demand for alternative services, and increased pressure on neighbouring trusts.