Parents Join Irwin Mitchell In Calling For Lessons To Be Learned
A baby was delivered stillborn 80 minutes after hospital staff wrongly believed a warning that he was close to death was an IT error, an investigation has found.
Staff at Queen’s Hospital in Burton believed that a message on a monitor measuring Theodore Swinburne’s heart rate which read ‘warning pre-terminal’ was a technical error rather than him being in distress.
When midwives and doctors realised the seriousness of Theodore’s condition around 40 minutes later, his mum Nickie, who had been admitted to hospital after saying she could not feel her baby move, was taken for an emergency caesarean under general anaesthetic. Staff unsuccessfully spent around 40 minutes trying to resuscitate Theodore.
Nickie and husband Andy, of Lichfield, Staffordshire, have now joined their specialist medical negligence lawyers at Irwin Mitchell in speaking out during Baby Loss Awareness Week by calling for lessons to be learned from their son’s death.
It comes after University Hospitals of Derby and Burton NHS Foundation Trust, which runs Queen’s Hospital, admitted liability and officially apologised to the couple aged 34 and 35, for the ‘mismanaged labour’.
In a letter Gavin Boyle, chief executive of the Trust, said: “I am profoundly sorry for the mistakes made and the shortfalls in care which occurred.
“Very clearly, the Trust did not meet the standards of care which you were fully entitled to expect and which we aim, at all times, to deliver. I hope it will be of some comfort to you to know that we are determined, as an organisation, to learn from the mistakes made in order to minimise the chance of it arising again.”
Expert Opinion“What should have been such a joyous occasion for Nickie and Andy ended in tragedy because staff failed to act on warning signs and missed a number of opportunities to deliver Theodore.
“Sadly, through our work, we see the pain and suffering that families experience because stillbirths and neonatal deaths are still a significant issue in the UK. The current figures from SANDS are that 15 babies a day die through stillbirth or neonatal death in the UK.
“While nothing will make up for Theodore’s death, we join Nickie and Andy in calling on the Trust to ensure it learns lessons from this tragic case so other families don’t have to endure the heartbreak of losing a baby in such unnecessary circumstances.” Eleanor Giblin - Senior Associate
Find out more about Irwin Mitchell's expertise in handling birth injury cases.
Nickie, a teacher, and Andy, a website developer, found out they were expecting their first child in October 2015. Nickie was due on 17 July, 2016.
On the morning of 25 July, 2016, the day before she was due to be induced, Nickie attended an antenatal clinic and reported feeling normal fetal movements.
However, by 8pm that evening she phoned Queen’s Hospital saying she had stopped feeling Theodore move. She was advised to attend the maternity unit.
Monitoring of Theodore’s heart rate through a CTG machine had started by 9pm. However, Nickie was left alone for an hour instead of a midwife intermittently returning to monitor the heart rate. When a midwife returned at 10.10pm they saw the ‘warning-pre-terminal’ notice and a deceleration in Theodore’s heart rate, a Serious Investigation Report said.
At 10.35pm a registrar concluded that Theodore may not be getting enough oxygen but Nickie was not in labour. They recommended changing the CTG machine but no concerns were raised to Nickie and Andy.
At 10.50pm staff decided to use another machine to monitor Theodore’s heart rate. His heart rate had started to fall and was then lost. The registrar was called once again and just before 11.25pm Theo’s heart rate – which was low - was detected. He was delivered around 10 minutes later.
The Serious Investigation Report published by the Trust concluded that the root cause of Theodore’s death was ‘a period of terminal asphyxia.’
It added that Theodore’s CTG results were ‘sufficiently abnormal’ by 9.50pm that a registrar should have reviewed them to determine whether a caesarean was necessary. By 10.10pm urgent action was required to perform an emergency caesarean and Theodore should have been delivered by 11pm at the latest.
Nickie said: “I woke up from a general anaesthetic to four words from Andy that will haunt me for the rest of my life: ‘he didn’t make it’.
“This devastation was then made worse when we would discover that Theo’s stillbirth had only occurred due to a catastrophic failure in care from our hospital.
“Returning home to a nursery that was ready and waiting, to clothes and toys that Theo would never wear and play with, was heart-breaking.
“Whilst no one could have prevented what caused Theo’s distress, our son could have been delivered alive within a couple of hours of us arriving at the hospital, had the correct protocols been followed. This unforgiveable event has changed our lives forever.”
Nickie added: “We cannot thank our immediate family, close friends and support groups such as SANDS and The Lily Mae for all the help and support they have given us.
“The support was and still is essential to us. Sadly, too many people find that they lose friends and are distanced from family members because the wrong things are said or the stillbirth not acknowledged.
“Even though he’s not here, Theo is still very much a part of our family and our lives. It is every bereaved parent’s worst fear that their child is forgotten, so remembering important anniversaries and allowing us to talk freely about Theo makes a world of difference.
“One of our favourite things is hearing our nieces say Theo’s name and talking about him. It hurts sometimes, but it’s so lovely that they know all about their special cousin.
“Sadly the truth is that there is no normal anymore. Assuming that all bereaved parents will go ‘back to how they were before’ is completely unrealistic. Just as new parents change as they adapt to life with a baby, bereaved parents do the same. I almost always put on a brave face to the world but inside I am continuously battling anxiety which is exhausting.
“My anxiety reached new levels whilst pregnant with our daughter Pippa who was born in April of this year. She is in no way a replacement for our baby boy but rather the continuation of the family that we wanted. It is important that people know that no baby can ever replace the ones that have died. Nothing can ever fill that void in our hearts, that now belongs to Theo.
“Every day there is a new mental challenge knowing that Pippa is doing the things that Theo never got the opportunity to do, the things that we’d planned for him and hoped he’d aspire to. But we are determined to live all of our lives as best as we can for him so that his life is lived through us. It is so hard but we try to be as positive as we can and try to do positive things in his memory.
“Sixty per cent of stillbirths are of unknown cause. This is one of the biggest things that people should be aware about. Many people assume that something was physically wrong with Theo when we tell them he was stillborn. In actual fact his post-mortem showed him to be a healthy, well-grown baby boy. The exact cause of death is unknown and we have to live with that every day, it makes it so much harder to understand grieve and try to understand ‘why’. He was a perfect little boy and we still lost him.
“Mothers should trust their instincts. I knew something was wrong when Theo missed his ‘wriggle hour’ so we called it in. It could have been so easy to wait until the next morning when we due to be induced, especially after seeing the midwife that very morning but my gut told me something wasn’t right.
“Unfortunately as first time parents, we put out trust in the staff in the hospital and relaxed on the ward after hearing what sounded to us like a healthy heartbeat on the monitor. Unbeknownst to us Theo was declining and due to massive errors from staff we had put our full trust in, he didn’t make it.”
Andy said: “Theo is always remembered by us. We take his little sister to visit him at the cemetery and his pictures are proudly displayed in our house alongside Pippa’s. We have channelled our grief through fundraising for the charities that have supported us through our journey so far.
“We have found that some of the best support for someone who has been through a stillbirth or neonatal death is to just be there to listen. Ask us how we are doing and don’t be afraid of upsetting us by saying our child’s name - it is filled with so much love - it’s one of the few things that we were able to give our children.
“We hope that by speaking out we raise awareness of the need to uphold the basic standards of hospital care that all patients deserve. We would not wish anyone else to have to experience the pain we continue to feel because of how our family was let down by those we put our trust in.”
Baby Loss Awareness Week aims to raise awareness of the issues affecting those who have experienced pregnancy loss or baby death in the UK. It also campaigns for improvements in healthcare, research and bereavement support.