Couple Seeks Assurances That Lessons Are Learned After Their Baby Died Just An Hour Old Due To Medical Staff Mistakes

The parents of a baby who died within an hour of her birth after a series of errors by medical staff are seeking assurances that the NHS will learn lessons from its mistakes after agreeing an out-of-court settlement with the hospital.

Stuart and Tracy Bray, 33 and 36, from Bradley in Huddersfield worked with medical experts at law firm Irwin Mitchell to investigate problems in the final stages of both the pregnancy and during the birth at the Huddersfield Family Birth Centre run by Calderdale & Huddersfield NHS Trust after losing their daughter Tily Ann in September 2009.

Tracy became concerned in the final stages of pregnancy after concerns were raised about her unborn baby’s growth but she was assured by staff on a number of occasions that everything was fine.

However an internal investigation carried out by the Trust was highly critical of staff and the equipment used after Tily Ann died just under an hour after her birth. It highlighted problems with the monitoring of her growth in the weeks leading up to the birth stating that further investigations should have been carried out which would have flagged Tracy as a high risk patient, something the hospital failed to do.

The handling of the labour was also criticised due to the significant loss of blood and the need for continuous monitoring not being adhered to. Other issues included:

• delays in calling an ambulance when Tracy was in labour;
• problems summoning a paediatrician; 
• resuscitation devices not functioning properly;
• and a lack of training of staff involved.

Irwin Mitchell has negotiated an out of court settlement with the NHS Trust on behalf of the family after hospital bosses admitted a breach of duty. The couple are now calling for the hospital to learn from the case in order to prevent other families going through a similar experience.

Sarah Coles, a medical law specialist at Irwin Mitchell, said: “Sadly, nothing can bring back Tily Ann, but we are keen to ensure that the NHS Trust improves patient safety by taking on board the criticisms in this case to try and prevent any further heartache in future.

“Tracy should have been monitored much more closely which would have resulted in an earlier delivery. Also, once she had started contractions, she should have been admitted to hospital much earlier as a high risk patient. Unfortunately, this was not the case and that failure has had a devastating impact on their lives.

“Losing Tily Ann was very traumatic for the family. They want to ensure that standards and procedures are improved and strictly followed in order to prevent any other families from going through what they did.”

Tracy Bray said: “We were devastated by the loss of our first daughter and, while we realise that nothing can bring her back, we would not wish any other family to experience the pain we have.

“In the final stages of the pregnancy I was scared that something wasn’t right but we were assured on a number of occasions that things were fine and that we were being monitored.

“We put our trust in medical staff but on this occasion we were obviously let down. We feel it is important that the Birth Centre listens to our concerns and make sure that it does not happen again.”

Background

Problems with Tracy’s pregnancy were first revealed in prenatal scans a month before her due date, which showed abnormal growth, but these results were not plotted. At a later scan the midwife again noticed a discrepancy in measurements, but no action was taken.

Tracy experienced irregular contractions four weeks later on 16 September 2009 at 39 weeks pregnant. She visited the Huddersfield Family Birth Centre on 18 September at 5am but was not admitted to the hospital and was sent home where she continued to experience contractions. She returned to the Family Birth Centre at 11pm that day but despite suffering considerable blood loss over the next few hours no action was taken until an ambulance was called for a transfer at around 1am on 18 September. By the time this arrived Tracy was in active labour and the transfer was cancelled as she continued to give birth.

Tily Ann was delivered at 4.30am and although she had a heart beat she was not breathing. A resuscitation device was brought into the room but wasn't functioning properly.  It wasn't until seven minutes later that a paediatrician was called who didn’t arrive until 35 minutes after the birth.  By this time Tily had no heart beat and at 5.25am she was pronounced dead.