Harrogate And District NHS Foundation Trust Admits ‘Avoidable Delays’ Caused Or Contributed To Death

A devastated couple from Knaresborough are campaigning for changes to maternity services after “avoidable delays” in delivery led to their baby daughter’s death.

Whitney Pickup was admitted to Harrogate District Hospital in labour in July 2018.  She was advised by doctors to proceed with a natural delivery, despite her first child being delivered via emergency caesarean section at another hospital.  Following an unsuccessful forceps delivery, her daughter Matilda was eventually born by caesarean section with severe brain damage.

Matilda was admitted to a neonatal intensive care unit at another hospital before being transferred to a hospice, where she died at nine days old.

Following their daughter’s death, Whitney, 33, and her husband Andy, 35, instructed medical negligence experts at Irwin Mitchell to investigate the care provided by the Harrogate and District NHS Foundation Trust, which runs the hospital. Irwin Mitchell is campaigning to improve maternity services across the country and has also contributed to the Health Committee’s Maternity Safety Call for Evidence.

The Trust conducted an investigation and admitted that “there were avoidable delays in achieving the delivery of Matilda which caused or materially contributed to her sad death.”

A Root Cause Analysis Report identified problems including a failure to obtain previous maternity and delivery notes, which would have alerted them to the risks involved as well as avoidable delays in the operating theatre and communication issues.

Recommendations were made “to establish a robust process for obtaining previous maternity and obstetric notes if applicable” including a date for when notes should be received and a plan of action if this did not happen.  It was also recommended to update the VBAC policy to “include documentation of relative risk factors and evidence that these have been discussed at the booking stage.”

The couple are now campaigning for Matilda’s Law to make it mandatory for hospital trusts to share antenatal, maternity and labour records if the mother is under the care of a different trust in future pregnancies.

Expert Opinion

“Losing Matilda in such a devastating way continues to have a profound effect on Whitney and Andy. What was meant to be a joyous time for the couple turned into complete heartbreak.

Through our work, we sadly come across too many families left to pick up the pieces following the death of a baby following avoidable failings.

We would urge Trusts to always work in partnership, not only by sharing patient records so the best possible care plans can be put in place, but also by sharing best practice. This we believe would reduce the number of mother and babies either seriously injured or killed.

We will continue to support Whitney and Andy as they continue to attempt to come to terms with their loss and progress with their campaign.”
Victoria Harris - Associate Solicitor

Whitney went into labour during the afternoon of 2 July 2018.  At around 11.45pm, Matilda’s heart rate was reported to be abnormal and Whitney began pushing.  By 1.10am on 3 July, Matilda’s heart rate had lowered.  Half an hour later, doctors attempted to deliver her using forceps.  The delivery was unsuccessful and a caesarean section was performed at around 1.45am.

Matilda was not breathing and required resuscitation.  She was transferred to Bradford Royal Infirmary, where she was cared for before being transported to Martin House Hospice on 12 July.  She died later that day.

Whitney and Andy also have two sons – Charlie, five, and Isaac, one.

Whitney said: “It’s still so difficult for me and Andy to accept that Matilda is no longer here and she didn’t get to experience any sort of life.

“What makes it worse and all the more upsetting is knowing our daughter’s death could have been avoided had the hospital simply requested my medical records, making them aware of the risks.

“It’s difficult not to think how Matilda should now be growing up and making memories with her family if it wasn’t for what happened.

“While we would give anything to be able to turn back the clock, we know it’s not possible.  So far, we haven’t had any support from the hospital Trust in question, but we’re so thankful that Matilda was transferred to Bradford Royal Infirmary and Martin House Hospice, who did everything they could for us.

“We will never forget Matilda and she will always be part of our family. We now want to honour her memory by it being law for trusts to share relevant information to improve patient care and ensure staff are aware of any potential complications.

“If we can prevent this happening to anyone else than at least we can take something from what we’ve had to go through.”

An inquest into Matilda’s death is due to begin at Harrogate Pavilion on 26 April and is listed for four days.

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