Mum Who Miscarried Four Times Gave Birth To Stillborn Son After Hospital Failed To Follow High-Risk Pregnancy Care Plan

New Mum Went To Hospital Five Times When Her Baby Stopped Moving But Staff Failed To Induce Labour Until It Was Too Late


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A heartbroken mum gave birth to her stillborn son after staff at a Nottinghamshire hospital failed to follow the high risk pregnancy care plan to induce labour at 39 weeks.

Stacey Lebond had already suffered four miscarriages, including the stillbirth of her son, Ayrton in April 2012, so medics at her local hospital in Essex put a pregnancy care plan in place to make her latest pregnancy as safe as possible.

But after the breakdown of her relationship in late 2014, Stacey moved to Nottinghamshire to be near family, coming under the care of staff at Bassetlaw District General Hospital in Worksop, who failed to follow the care plan even when she attended five times when the baby was barely moving.

Stacey instructed expert medical negligence lawyers Irwin Mitchell to investigate her and Tobias’ care under Doncaster and Bassetlaw Hospitals NHS Foundation Trust to see if anything could have been done to prevent her son’s death.

The Trust, which launched its own Serious Untoward Incident (SUI) investigation following Tobias’ death, has apologised to Stacey for what it called “missed opportunities” to induce labour.

But Stacey, who is speaking out following Stillbirth and Neonatal Deaths (SANDS) Awareness Month in June, said more needs to be done to prevent the same heart-breaking mistakes happening to other parents – including listening to a mother’s instinct.

The 26-year-old accountancy student said: “Tobias would be 16 months old now. I should be taking him to play group not visiting his grave.

“An apology won’t mend a broken heart or bring my little boy back. But by recognising and acknowledging their mistakes and taking steps to improve maternity care the hospital will hopefully ensure no other parent loses a baby the same way I did.

“As an expectant mother you take your doctor’s word as gospel as they are the professionals. So when my doctor said she didn’t understand why I should have an induced labour at 39 weeks, I didn’t argue. I explained my history and expected she would know what to do. Tobias paid the ultimate price for that and both my mum and I have blamed ourselves over his death because we didn’t argue with the doctor or midwives. They had our trust.

“Parents need to feel confident in speaking frankly about their concerns with doctors and midwives, and the medical professionals need to listen. Not every worry is simply new-mum nerves, as I learned with Tobias.”

Stacey, who has another son, Isaac, three, was admitted five times between January 27 and February 8, 2015 after Tobias, a normally active baby stopped moving as frequently. On each occasion midwives checked Tobias’ heartbeat and reassured Stacey that he was fine, before sending her home.

On February 10 – two days after Stacey’s last panicked visit – Tobias had stopped moving completely. Stacey went to hospital where midwives used a portable scanner to try to find a heartbeat. But despite getting a reading, there was no one in the hospital who could interpret it, meaning Stacey had an agonising overnight wait before learning Tobias had died.

Stacey was induced on the same day, at 40 weeks and one day of pregnancy. Little Tobias was born on February 12, 2015 weighing 7lbs 5oz and was buried next to his brother Ayrton on February 27.

Expert Opinion
“Having suffered the heartbreak of four miscarriages – one ending in a distressing stillbirth, Stacey felt confident that she was coming under the care of Bassetlaw District General Hospital already armed with a high risk pregnancy care plan. "So to lose Tobias and then learn that following that there were missed opportunities to save him was a bitter blow from which she is still trying to recover.

“What was particularly concerning was the disregard to Stacey’s concerns when she presented at the hospital with reduced movement from her baby. On these occasions Stacey’s case should have been escalated to an obstetrician – a decision which could have saved Tobias’ life.

“Stacey hopes that by admitting liability and apologising for its mistakes, the Trust will have learned from this tragic case and avoid causing further suffering to other expectant parents.”
Helen Jones, Solicitor

The SUI report revealed that root cause of Tobias’ death was “a missed opportunity to induce Ms Lebond’s labour when she presented with reduced foetal movements on February 8.

The report also identified an opportunity to intervene earlier in the pregnancy when Stacey presented with reduced foetal movements on January 27.
It said: “Intervention at that time would have led to further scans and dopplers and had a problem been identified, it would be reasonable to say that her labour would have been induced at an earlier stage.”

The report gave five recommendations, including raising awareness of the importance of obtaining medical records when women transfer from a different hospital trust during their pregnancy. The Trust said it would carry out an audit of the hospital regarding this type of record-keeping.

The Trust said it would also develop in-house training packages to highlight the importance of escalating to obstetricians any high-risk patients or patients presenting with multiple episodes of reduced foetal movements. The individual midwives who failed to escalate Stacey’s case would be referred to the supervisor of midwives and ward manager for individual management around policies and procedures.

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