We don't know what happened. These four years have just been torture.
In the quiet aftermath of a birth that became a death, Kianty and Conor Simpson have spent four years suspended between grief and bureaucracy — unable to bury their son Jacob, unable to receive a death certificate, unable to learn why he died. A Welsh hospital admitted negligence, investigators identified clinical failings, yet the machinery of accountability moved so slowly that a family was left holding ashes they could not scatter. Only when journalists began asking questions did the coroner's office acknowledge the delay and schedule a hearing — a reminder that institutional systems, however well-designed, can fail the very people they exist to serve.
- A newborn died after twenty-two minutes of resuscitation, his brain starved of oxygen during a labor that multiple investigators would later identify as mismanaged — yet four years on, no inquest has been held and no death certificate issued.
- The health board's own review named the failings clearly, then abruptly halted its investigation the moment the family sought legal representation, leaving them in a procedural void with no path to answers.
- Staff shortages compounded by the pandemic left the coroner's office unable to prioritize the case, and the family's grief calcified into something harder — anxiety through a second pregnancy, an inability to parent their living son without the weight of the unresolved first.
- A compensation offer arrived with a twenty-one-day deadline; the family declined, insisting that money without truth is not justice.
- Only after BBC scrutiny did the coroner issue an apology and schedule a pre-inquest hearing — a small but significant turn toward the accountability the Simpsons have been seeking since 2022.
Jacob Simpson was born on June 16, 2022, at Glangwili Hospital in Carmarthen, Wales, and died four days later. His father Conor knew something was wrong the moment Jacob emerged — pale, unresponsive, requiring twenty-two minutes of resuscitation. The cause was catastrophic oxygen deprivation during labor. After transfer to Singleton Hospital for cooling treatment, Jacob did not survive.
Conor, an Army officer posted to west Wales, had learned of the pregnancy through a surprise Kianty had carefully arranged — a hidden camera, a box over dinner, baby clothes and positive tests inside. The joy of that moment now stands in impossible contrast to the hospital room where they held their son as he died.
What followed was not grief's natural course but a prolonged institutional failure. The NHS health board identified multiple clinical shortcomings — poor communication, inadequate fetal monitoring, failure to escalate care. But when the Simpsons hired solicitors, the board halted its own investigation, directing the family toward an inquest that was never scheduled. No death certificate was issued. The coroner's office, understaffed and overwhelmed in the wake of the pandemic, did not treat the case as urgent. In early 2026, the health board admitted negligence and offered compensation with a tight deadline. The family refused.
Only after the BBC began asking questions did Coroner Gareth Lewis write to the family with an apology, citing staff shortages, and confirm that Jacob's inquest would now be prioritized — a pre-inquest hearing scheduled for the following month.
The Simpsons have since moved to Lincolnshire and welcomed a second son, Luke, now nearly eighteen months old. But Jacob's unresolved death shadows everything. Kianty's pregnancy with Luke was defined by dread. Conor finds himself unable to answer the ordinary question — is this your first child? — without confronting a loss that has never been formally acknowledged. He feels he cannot be fully present for Luke while still fighting for Jacob. The family does not seek only compensation. They want to understand what happened, and they want that understanding to protect other families from the same unbearable wait.
Four years have passed since Jacob Simpson took his first breath and his last. His parents, Kianty and Conor, still have not scattered his ashes. They do not have a death certificate. They do not know why he died.
Jacob was born on June 16, 2022, at Glangwili Hospital in Carmarthen, Wales, after his mother's labour was induced. What should have been a moment of joy became something else entirely. When the baby emerged, Conor saw immediately that something was catastrophically wrong. Jacob was pale, bluish, lifeless in appearance. He required resuscitation for twenty-two minutes. The doctors told the parents their son had suffered a profound lack of oxygen to his brain during birth. He might not survive. If he did, he would likely be severely disabled. Four days later, after transfer to Singleton Hospital in Swansea for cooling treatment to reduce brain swelling, Jacob died.
The couple had been living in Pembrokeshire when Conor, an Army officer, was posted to west Wales. Kianty had surprised him with the news of her pregnancy in a way that now feels impossibly distant—a hidden camera, a box presented over dinner, baby clothes and positive tests inside. "I'd had a really bad day at work," Conor recalled, "and all of a sudden, all those worries just vanished. The only thing I was focused on was just being a dad." That focus, that anticipation, that ordinary hope—all of it ended in a hospital room where they held their son as he died.
What followed was not closure but a maze. The health board's own investigation, conducted under the NHS Putting Things Right process, identified multiple failings: poor communication, failure to inform the parents of concerns, inadequate fetal monitoring, failure to escalate care. But when the Simpsons hired solicitors to pursue their case, the health board halted its investigation in June 2024. The family was told they would need to wait for an inquest to understand what had happened. No inquest was scheduled. No death certificate was issued. Four years passed. The coroner's office, understaffed and overwhelmed, did not prioritize the case. The health board admitted negligence in January 2026 and offered compensation in February with a twenty-one-day deadline. The family declined.
Only after the BBC inquired about the delay did the coroner, Gareth Lewis, send a letter of apology. Staff shortages, he explained, had made it difficult to balance new cases with existing ones, a problem "exaggerated by the Covid pandemic." He assured the family that Jacob's inquest was now a priority. A pre-inquest hearing was scheduled for the following month. Four years. The solicitor representing the family, Chantelle Cooper, called the delay "very unusual." "We've had an admission of liability," she said. "We know there are failings, something went wrong. To be four years along without answers, it's unbearable."
Conor and Kianty have since moved to Lincolnshire and had another child, a son named Luke who is nearly eighteen months old. But the shadow of Jacob's death has not lifted. Kianty's entire pregnancy with Luke was consumed by anxiety, by the expectation that something would go wrong again. Conor struggled with parenthood itself, haunted by the triggers of ordinary questions—Is this your first child? How do you answer that when your first child is dead and you have not yet buried him? He feels he cannot give Luke the full attention he deserves while still "fighting for Jacob." The couple say they cannot move forward, cannot grieve properly, cannot find peace, because they do not know what happened. They do not know why their son died. They want answers not just for themselves but so that other families might be spared the same loss. They are waiting for an inquest that should have happened years ago.
Notable Quotes
I just had an overwhelming sense of just panic because he looked dead and that was difficult. It's meant to be a happy moment. We were just watching him get resuscitated for 22 minutes and that was just awful.— Conor Simpson, describing Jacob's birth
We've had an admission of liability, so we know there are failings, something went wrong. To be four years along without answers, it's unbearable.— Chantelle Cooper, family solicitor
The Hearth Conversation Another angle on the story
What does it mean, practically, that there's been no inquest for four years? What does that actually prevent them from doing?
It prevents them from having an official, independent examination of what went wrong. The health board's own investigation identified failings, but it stopped when lawyers got involved. Without an inquest, there's no formal legal process, no public record, no binding conclusions about causation. They can't scatter the ashes because culturally, spiritually, you need closure—and closure requires knowing.
But the health board admitted negligence. They admitted the death was avoidable. Doesn't that answer the question?
It answers part of it. It says something went wrong. But it doesn't say what, precisely, caused Jacob to die. Was it a specific decision? A failure to act at a particular moment? The family wants expert evidence, independent neonatology review. They want to know the exact chain of events so they can understand and, more importantly, so they can advocate for change.
Why did the investigation stop when they hired solicitors?
That's the system working as it's designed to work, technically. Once legal action is anticipated, the health board's internal process typically pauses to avoid prejudicing the case. But from the family's perspective, it feels like the moment they tried to get answers, the door closed.
And the coroner's office—staff shortages seem like an explanation, not an excuse.
True. But four years is a long time to wait while your child's ashes sit in a box. The coroner acknowledged it was unusual, apologized, and suddenly found the capacity to prioritize. That suggests the capacity was there; the case just wasn't treated as urgent until external pressure arrived.
What do they hope the inquest will actually change?
They want to know what happened to Jacob. But they also want lessons learned, systemic change, so no other family endures this. They're not just seeking answers for themselves—they're trying to prevent the next death.