NHS Trust Investigation Said Human Error and Inadequate Care Led to Death of Baby Girl at King’s Mill Hospital

A mum-to-be who begged hospital midwives to take her to the birthing centre gave birth to a stillborn daughter as staff insisted she was not in labour delaying her vital care.

Becky Malpass from Mansfield, Nottinghamshire had telephoned King’s Mill Hospital after her waters broke at home, but despite telling midwives as her pain increased that she was in labour, they insisted she was not and suggested that she monitor this before calling back again.  Approximately 48 hours after first complaining of severe pain, her daughter Freya Malpass-Davies was stillborn. Becky’s placenta had ruptured, starving Freya of oxygen.

Becky, age 28, and partner Jordan Davies, Freya’s father, instructed expert medical negligence lawyers at Irwin Mitchell to investigate her care under Sherwood Forest Hospitals NHS Foundation Trust.

Sherwood Forest Hospitals NHS Foundation Trust launched a Serious Untoward Incident investigation and concluded that “human error led to inadequate care being assessed, planned and implemented which led to the sad death of Miss BM’s baby.”

It added that the registrar failed to provide a senior review when asked and two midwives failed to escalate their concerns beyond the registrar.

The Trust identified five lessons from Becky’s care including that any concerns should be escalated and must be persistent if unease persists; women with a high-risk pregnancy should have a plan of care made by the registrar/consultant when presenting in triage and that record keeping can be improved.

Becky said: “An apology won’t make things right. It won’t bring Freya back. But by identifying failings and lessons from her death I hope steps will be taken to improve maternity care and ensure no other parent loses a baby the same way I did.”

“As an expectant mother you have faith in those treating you - they are the professionals after all – but I was scared, and in pain.”

“After I’d been told Freya had died, a midwife told me she didn’t feel Freya had been dead long as she was ‘too fresh’. “The agony of not knowing how close I was to giving birth to Freya early enough to save her will stay with me forever.”

The SUI report returned five recommendations, including;

• Staff need to be more vigilant of women presenting with high-risk pregnancies to ensure that all plans of care reflect problems alongside existing complications. Consultants should be involved and kept informed of events.
• Continued education of foetal heart monitoring for all staff.
• Improvement in escalation within the maternity unit is essential and must be used in all aspects of care.
• All staff involved must reflect on this case and learn from decisions that were made that impacted on the care received by Miss BM.

Kimberley Nightingale, an expert medical negligence lawyer at Irwin Mitchell, representing Becky, said: “What is particularly concerning about Becky’s case is the disregard to her concerns when she presented at the hospital having experienced her waters breaking with reduced movement from her baby and then her increasing pain. In this situation, Becky’s case should have been escalated to an obstetrician – a decision which could have saved Freya’s life.

“Becky hopes that by acknowledging its mistakes, Sherwood Forest Hospitals NHS Foundation Trust will have learned from this tragic case, to avoid similar mistakes and distress in the future.”

Read more about the work of Irwin Mitchell's Medical Negligence Team.