Walsall Couple’s Baby Pronounced Stillborn After Hospital Trust Missed Opportunities To Review Care Plan

A Hospital Trust “missed opportunities” to review a pregnant woman’s care plan after not acting upon concerns about her baby’s growth before she was stillborn, an investigation found.

During her first pregnancy Amy Walters had been placed under the care of Walsall Healthcare NHS Trust, with her pregnancy initially being assessed as “high risk”.  

The 24-year-old attended appointments during which baby Heidi’s growth was found to be below average. 

Amy, of Bloxwich, Walsall, had her final growth scan on 29, November, 2022, at 35 weeks. 

Amy attended hospital concerned over baby Heidi's movement

Amy attended follow up ante-natal clinic appointments on 7 and 12 December. At the second appointment, Heidi’s growth wasn’t measured and Amy said she was told everything was fine. Amy was booked to see a midwife on 4 January but she was admitted to Walsall Manor Hospital on Christmas Day concerned about reduced movements of her baby. She was discharged the following day. 

On 4 January no issues were raised during a midwifery appointment and she was booked for an induction on 13 January.

However, the following day Amy, who was 40 weeks pregnant, attended the maternity unit at Walsall Manor Hospital concerned about bleeding. Amy asked for an induction of labour to be brought forward. However, she said this was rejected because there was no capacity and other patients had already been booked in. 

Following tests, Amy was sent home. However, she continued to be concerned about her baby’s reduced movement and attended hospital again just before 11am on 7 January.  

Staff couldn’t find a heartbeat and Amy was told Heidi had died. Amy was induced and delivered Heidi just after 3am the next day. 

Amy and partner Jordan asks medical negligence lawyers to establish answers 

Following Heidi’s death Amy and her partner Jordon Quilt, 25, instructed expert medical negligence lawyers at Irwin Mitchell to investigate Amy’s care under Walsall Healthcare NHS Trust and help them access the specialist support they require.  

Amy is now using Baby Loss Awareness Week to speak for the first time about her ordeal and in calling for lessons to be learned from their tragic loss. 

Hospital Trust report finds family's care didn't meet regional or national guidelines 

It comes after an investigation report by the Trust found several missed opportunities to review Amy’s care and assess Heidi’s growth, including on 7 and 12 December as well as on Christmas Day. 

Amy’s initial care management didn’t meet national or regional care guidelines, the report said. It added the care issues identified “were likely to have made a difference to the outcome for the baby.”

Trust apologises to Amy and Jordan

In a letter to Amy, the Trust said “there were things that could have been done differently” for which it was “extremely sorry.” In the letter, it added that Amy should have had another growth scan at 39 weeks. 

As Heidi was very small when she was delivered, it’s possible that a growth scan at 39 weeks “would have picked this up and we would have acted by way of inducing labour before Heidi passed away,” the Trust said.

Expert Opinion

“This is a truly tragic case in which worrying issues in the care Amy and Heidi received have been identified by the Trust itself.

“Amy and Jordon are devastated by the events that unfolded and Heidi’s death. What should have been such a happy time for the family ended in heartache.

“While nothing can ever make up for their loss we’re determined to provide Amy and Jordon with all of the answers they deserve.

“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 safety.

“We urge the Trust to learn lessons from the issues identified to prevent other families having to endure the pain Amy and Jordon are going through.

“Patient safety should be the fundamental priority and we continue to campaign for improvements in maternity care.” Kayleigh Hunter

Amy reveals impact Heidi's death has had on couple

Amy said: “It’s almost impossible to find the words to describe what they last few months have been like. When we found out we were expecting we were overjoyed and couldn’t wait to welcome Heidi into our lives. 

“Initially I felt reassured that I was under the care of doctors and thought that would mean I would receive the best care possible. However, after 35 weeks I started to be concerned as Heidi was plotted as being small.

“However, each time I tried to raise concerns in appointments, or visited hospital, it felt like I wasn’t really being listened to. After New Year I knew deep down something wasn’t right. I wanted to stay in hospital as I thought that would be the best place for me and Heidi could be monitored, but I was sent home.

“Those couple of days after being sent home before returning to hospital were awful. Nothing prepared us for the news Heidi had died. We were shattered. Having to then deliver Heidi just added to the distress we were going through.”

Walsall couple fundraise for charity as they support Baby Loss Awareness Week

Following Heidi’s death, Amy had to take time off from her job as a dispatch co-ordinator but is now working full time again following a phased return. 

Her and Jordon, an environmental waste operative, are now keen to help those organisations that offer support to bereaved parents in similar situations. 

Along with friends and family, and their dog, last month they walked 100 kilometres to raise money for the charity SANDS.  This month they are now walking to raise money for 4Louis. 

Amy added: “While we’ll forever cherish those few precious moments we got to spend with Heidi, it’s difficult not to think of how she should be at home with us.

“We had so many plans for the future. All we wanted was to bring Heidi home and start our family life together. 

“The last few months have been a real mix of emotions and we’re so thankful for the help and support we’ve had.  All we can do now is share what happened to us to make other parents aware. I want to encourage any first-time mums in particular to always listen to those gut feelings and always speak out if you feel that something isn’t right. 

“By speaking out we just hope lessons can be learned. We wouldn’t wish what we’re going through on anyone. Support is available and nobody should have to go through the ordeal of losing their baby alone.”

Baby loss support available

Baby Loss Awareness Week runs between 9-15 October. More information about the support available to families can be found on the SANDS website. 

Find out more about Irwin Mitchell's expertise in supporting families affected by issues in maternity care at our dedicated birth injuries section. Alternatively, to speak to an expert contact us or call 0370 1500 100.