Aberdare Woman Instructs Medical Negligence Lawyers To Help Secure Answers
A mum’s baby was delivered stillborn two days after she was wrongly sent home from a Wales hospital, an official investigation has found.
Hayley Ryan, 43, and her legal team at Irwin Mitchell are calling for lessons to be learned after a NHS investigation report into her baby’s death found six “care problems”. These included that the decision to send her home from hospital was “inappropriate”.
Further to the care problems medics also missed a diagnosis of acute fatty liver of pregnancy (AFLP) - a serious complication that can result in the death or profound disability of a mother and her newborn.
Hayley admitted to Prince Charles Hospital
Hayley, who was deemed a high-risk pregnancy, had been admitted to Prince Charles Hospital in Merthyr Tydfil on 9 June, 2020, complaining of vomiting, abdominal pain, lower backache and not passing urine.
Doctors believed she may have a water infection and placed Hayley on the ‘sepsis pathway’ – which sees patients undergo tests to establish whether a patient has the condition which sees the body attack itself in response to an infection.
Hayley, of Aberdare, was prescribed strong painkillers but no stomach ultrasound was carried out to investigate her abdominal pain. Her blood test and liver function test results were abnormal, an investigation report by Cwm Taf Morgannwg University Health Board, which runs Prince Charles Hospital found.
Hayley was discharged the following afternoon without the cause of her symptoms being fully established, to attend a community midwife appointment on 11 June, the report said.
During the appointment she complained of continued pain and bleeding. She wasn’t referred to hospital.
Aberdare mum told baby Zaiyan had died
Hayley’s symptoms continued and she was re-admitted to hospital on the afternoon of 12 June, 2020. Within 10 minutes she had been told the news that her son Zaiyan had died.
Hayley was induced and delivered Zaiyan around six hours later.
Following delivery, she was transferred to intensive care after concerns were raised about her abnormal liver function and a possible diagnosis of AFLP. Three days later she was transferred to hospital in Birmingham for specialist treatment.
Hayley spent four days in an induced coma. When she woke up she was disorientated and had to be told she had lost her baby. She was discharged from hospital on 22 June, 2020.
Medical negligence lawyers asked to secure answers for Hayley
Following her ordeal Hayley made an official complaint to Cwm Taf Morgannwg University Health Board, which runs Prince Charles Hospital. However, after believing the Board was taking too long to deal with her complaint, she instructed expert medical negligence lawyers at Irwin Mitchell to secure answers regarding her care under Cwm Taf Morgannwg University Health Board and help her access the specialist support she requires.
She has joined her legal team at Irwin Mitchell in calling for lessons to be learned to improve maternity safety.
Health Board investigation report finds care problems
It comes after the Board’s investigation report, which Hayley received two years after lodging her complaint, found six care problems in Hayley’s care.
• It was “inappropriate” to discharge Hayley when she was still requiring morphine for pain relief
• The decision for her to be reviewed by a community midwife the day after returning home was “inappropriate”. She should have been advised to attend hospital for an obstetric review and repeat blood tests
• There was “unclear clinical medical leadership” of Hayley’s high-risk pregnancy and abnormal blood results weren’t acted upon
• There was a “failure to recognise abnormal observations” and act upon them correctly
• There was a “failure” to organise an ultrasound scan
• Hayley wasn’t referred to hospital when she flagged continued pain and bleeding during her community midwife appointment.
As well as the care problems, the report found a root cause of Zaiyan’s death was a missed diagnosis of AFLP.
Areas for learning identified
The report identified eight areas for learning.
• The need for “an immediate” obstetric review when a woman triggers the sepsis pathway
• The need to “appropriately monitor” women and when a patient remains in pain despite taking strong painkillers
• Referring their case for a review by surgeons should be considered.
• That an abdominal ultrasound wasn’t carried out
• That Hayley wasn’t offered a review in hospital when she flagged bleeding to the community midwife
• Discharging her from hospital should only have been considered when her symptoms were resolved and made clear to Hayley
• To not prescribe paracetamol when liver function tests are abnormal
• A “clear plan” for follow up and referral should have been given to the community midwife when Hayley was sent home.
Expert Opinion“Hayley has been left absolutely devastated by what happened to her and Zaiyan. Understandably the last couple of years and trying to come terms with her loss, while having so many unanswered questions about the care she received, has been incredibly difficult.
“The findings of this report make for harrowing reading with the Health Board identifying a number of worrying issues in Hayley’s care.
“Sadly through our work we continue to see too many families who have been left trying to pick up the pieces as a result of issues in maternity care.
“While we welcome the Board’s pledge to learn lessons it’s now vital that these are upheld at all times to improve maternity safety.
“The first-hand account we’ve heard from Hayley also points to concerning areas in how her complaint was handled. We urge all health trusts and boards to ensure they listen to patients to not only provide the timely answers they deserve but also ensure that, where appropriate, opportunities to learn lessons are implemented and shared as soon as possible across the wider NHS to improve care for others.” Eleri Davies
Devastated Hayley's fight for answers
Hayley, who has two other children, said: “The last two years and trying to come to terms with Zaiyan’s death has been the most traumatic time I could ever imagine.
“When I was in hospital I told the doctors and nurses how unwell I was but I just felt that my concerns weren’t listened to properly. I knew something wasn’t right and didn’t want to go home but it felt like I was given little choice but to do so.
“Once home the pain continued and I started bleeding. I could still feel Zaiyan moving and hoped everything would be okay but deep down I was scared and thought being in hospital would be the best place for me.
“When I was re-admitted to hospital it was only a few minutes before I was told my baby had died. At that point my world crumbled. I remember delivering Zaiyan and how difficult that was emotionally but the next thing after that I remember was waking up and being so confused and disoriented that I had to be told I was 100 miles from home and I’d lost Zaiyan.
“Attempting to try and grieve for him has been made all the harder by having so many questions and concerns about what happened. However, after everything I’d gone through, I still felt like I wasn’t being listened to. Even after lodging an official complaint I tried several times to contact the hospital to try and get some answers. Each time my details were taken and I was told someone would get back to me but they never did.
“It got to the point where I started questioning myself wondering whether I could have done something different. It felt like my concerns were only taken seriously after launching a legal case.
“I don’t think I’ll ever get over the pain of losing Zaiyan and only wish he was at home with us growing and developing. I know nothing can turn back the clock and while they’re incredibly upsetting and distressing, I take some small comfort from at least now having some of the answers that I and Zaiyan deserve.
“All I can hope for now is that lessons are learned from not only my care but also how families going through the most difficult of times rightly have questions around what happened. Health boards and trusts need to ensure families are treated with compassion and listened to so they can be provided with answers without having to fight for them.”
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