Parents of a four-day-old baby who died following multiple failings during his birth four years ago say they are no closer to understanding what happened.
- +Our newborn baby died four years ago and we still don't know why
Kianty and Conor Simpson, from Lincolnshire, have yet to scatter son Jacob's ashes as no inquest has been held into his death and they still do not have a death certificate for him.
Kianty and Conor Simpson, from Lincolnshire, have yet to scatter son Jacob's ashes as no inquest has been held into his death and they still do not have a death certificate for him.
Jacob suffered a lack of oxygen to his brain during his birth at Glangwili Hospital, Carmarthen, in June 2022 before his life support machine was turned off days later.
The coroner for Carmarthenshire and Pembrokeshire has apologised to the family for the delay and said their son's case was now a "priority".
"No-one can explain what the feeling is like of having to take a baby seat out of your car or to take the 'baby on board' sign off the back before driving home," said Conor. "The whole experience was extremely traumatic".
The couple were living in Haverfordwest, Pembrokeshire, when Conor was posted to west Wales with the Army and Kianty fell pregnant.
At the time, she set up a hidden camera and filmed herself handing him a box over dinner, telling him it was an early birthday present. Inside, there was a note telling Conor he would make a "great father" along with baby clothes and Kianty's positive pregnancy tests.
"I'd had a really bad day at work…and all of a sudden, all those worries just vanished. The only thing I was focused on was just being a dad," said Conor.
On 15 June 2022, Kianty was taken to Glangwili Hospital to be induced but her labour started spontaneously.
After initially progressing well, by the following afternoon labour had slowed.
"For a first-time mum, I had no idea what it was meant to feel like and how long it was meant to take," she recalled.
It was only when Jacob was finally born that Conor instantly recognised something was wrong as his son was "pale, bluish".
"I just had an overwhelming sense of just panic because he looked dead and that was difficult," recalled Conor.
"It's meant to be a happy moment. We were just watching him get resuscitated for 22 minutes and that was just awful."
The couple were told that Jacob was gravely ill, had suffered a catastrophic lack of oxygen to his brain and although he had been resuscitated, he might not survive.
If he did, he might be severely disabled.
He was transferred to Singleton Hospital in Swansea where he was given cooling treatment to reduce the swelling on his brain, but four days later, Jacob died.
"The staff were incredible," Kianty said. "They helped us make some little foot mouldings and we had the opportunity to hold him at the end."
Conor has suffered prolonged effects from the aftermath of Jacob's birth.
"Kianty is such a lovely person," he said. "I'm just thinking why does it have to happen to her."
He said stepping outside the hospital to call family and let them know Jacob had died was the most difficult phone call he has ever had to make.
The couple say they are struggling to move forward with their lives because after they instructed solicitors to help with their case, Hywel Dda University Health Board stopped its own investigation under the NHS Putting Things Right process in June 2024.
Before it was halted, the probe had identified a number of failings during Kianty's labour which were shared with the family, including poor communication, failure to inform the Simpsons of concerns, inadequate fetal monitoring and failure to escalate care.
The family say the investigation did not include independent neonatology expert evidence to indicate more precisely what might have caused Jacob's death and were told they would need to await his inquest.
"In the event of a serious incident we have robust processes in place for reviewing the incident internally, identifying any issues and, where appropriate, preparing an improvement plan to prevent such an occurrence in the future," she said.
"We regret any such incidents and always seek to learn from them."
The health board later admitted negligence in January 2026 when they recognised Jacob's death was avoidable.
In February 2026, the Simpsons received a compensation offer from the board with a 21-day deadline to accept, which they declined.
After the BBC contacted the coroner for Carmarthenshire and Pembrokeshire to ask why after four years, Jacob's inquest was still yet to be heard, a letter of apology was emailed to the family.
In it, senior coroner for Carmarthenshire and Pembrokeshire Gareth Lewis said his office had experienced staff shortages which had left them struggling to balance new cases with existing ones "exaggerated by the Covid pandemic".
He assured the family that Jacob's inquest was now a "priority" with an "urgent review" of all documentation already received by his office, and suggested a date for a pre-inquest hearing next month.
Representing the family, Chantelle Cooper from Switalskis Solicitors, said it was "very unusual" for an inquest to take this long to be heard.
"We've had an admission of liability, so we know there are failings, something went wrong," she said. "To be four years along without answers, it's unbearable".
The family solicitor added the Simpsons were determined to know what "lessons have been learned" so that no other families have to go through the same.
The couple now live in Lincolnshire and have gone on to have another baby, but Kianty says her entire pregnancy was overshadowed by anxiety.
"I was kind of expecting it to end badly, not to get to the end of the pregnancy," she said. "I hadn't prepped for after he was born."
Luke is nearly one-and-a-half and his parents say he is a "lovely, lovely boy" and very "special" to them, but Conor said he initially struggled with parenthood.
"There are lots of triggers, people just asking, is this your first? How do you answer that?" he said. "It's not easy to be a parent when you've suffered loss."
He also feels that they cannot give Luke all the attention he deserves while they are still "fighting for Jacob".
They hope that Jacob's inquest will progress to a full hearing soon so that the family can find "some peace".
"These four years have just been torture. What we've been lacking as parents, is coming to terms with what's happened, because we don't know what happened."
