Baby Loss Awareness Week

A baby was pronounced stillborn after a monitoring machine's alarm had been switched to silent and a pathological heart rate reading went unrecognised, an investigation found.

Bethany Sowerby, 32, attended The James Cook University Hospital in Middlesbrough after becoming concerned about her baby's movements while 38 weeks pregnant. Bethany was dropped off at the hospital by her mother-in-law.

Staff started electronic monitoring of the baby’s heart rate while they attended to other patients. Around 30 minutes later Bethany noticed the machine had suffered a paper jam. Staff struggled to find a heart rate and Bethany was transferred to the delivery suite.

Shortly afterwards Bethany, who had previously visited hospital during her pregnancy concerned about her baby’s movements, was told her daughter Hattie Sowerby had died.

Following Hattie’s death, Bethany, of Redcar, instructed expert medical negligence lawyers at Irwin Mitchell to investigate her care under South Tees Hospitals NHS Foundation Trust and help her access the specialist support she requires.

It comes after an independent investigation report by the Healthcare Safety Investigation Branch (HSIB) found that the heart rate monitoring machine’s alarm had been triggered at the time of the paper-jam, but the settings had been switched to silent.

A re-print following the paper jam found Hattie’s heart rate monitoring to be pathological but this was not recognised until after she died.

Investigators found staff were unfamiliar with key alarm functions on the heart rate machine, meaning the alarm sound had been turned off, and that the pathological reading was not recognised until after Hattie's death had been diagnosed. The HSIB report said this was likely to have impacted on the outcome for Hattie.

Bethany has revealed how she has suffered significant psychological injuries following the loss of Hattie. She has been diagnosed with PTSD and continues to require medication and therapy to help her cope with the impact of her loss.

Bethany is using Baby Loss Awareness Week to speak publicly about the impact of Hattie’s death on her family and their search for answers.

Katy Daws, specialist medical negligence lawyer at Irwin Mitchell representing Bethany, said: 

“Bethany's maternity experience was extremely traumatic and the loss of Hattie continues to have a profound impact on her life.

 

“Both her and Matthew are still struggling to come to terms with their heartbreaking loss at what should have been a time of celebration.

 

“Our priority is now ensuring Bethany receives the support and specialist treatment she needs.

 

“In the meantime, the findings of the investigation report are deeply concerning and identify a number of issues. It’s vital that lessons are learned to improve maternity safety for other families.”

Throughout her pregnancy, Bethany sought medical advice whenever she became concerned about her baby's movements. Due to recurrent episodes of reduced fetal movements, plans had been made to induce labour at 39 weeks, on 21 May 2023.

On 15 May 2023 at 8.35pm, Bethany attended the Maternity Triage Unit at The James Cook University Hospital at 38 weeks and one day pregnant after experiencing an episode of reduced fetal movements.

When she arrived, a midwife carried out an initial assessment and used a handheld monitor to check the baby's heartbeat, which was found to be normal.

At 9pm Bethany was then connected to an electronic heartrate monitoring machine, which continuously monitors a baby's heart rate and wellbeing. She was given a call bell before a midwife left to care for other patients.

Around 30 minutes later, Bethany noticed the paper had jammed and the machine did not appear to be recording properly. She alerted a passing staff member and, when the monitor was checked, her baby's heart rate was found to be below the normal range.

Investigators later found that an alarm had been triggered on the CTG monitor at the time the paper jammed. However, staff were not alerted because the machine's audible alarm had been switched off.

Several midwives and a doctor attended but were unable to locate the baby's heartbeat.

At around 9.34pm, Bethany had an ultrasound scan, which revealed that the baby's heart rate had slowed dramatically. She was told her baby needed to be delivered immediately by emergency caesarean section and that survival was uncertain.

As Bethany and the emergency team prepared for surgery, a second ultrasound scan confirmed that Hattie’s heart had stopped.

Sadly, Hattie was pronounced dead at 9.43pm. A post-mortem examination later found Hattie had been deprived of oxygen before her death, the report found.

Bethany, who has three children, Ella Sowerby, 12, Olivia Sowerby, nine, and Oakley Sowerby, two, with partner Matthew Sowerby, 33, delivered Hattie the following morning.

Bethany, said: 

“Our little Hattie would have turned three this spring and we'd have celebrated so many milestones by now, her first birthday, first words and first steps.

 

“But the reality is that I never got to take our daughter home from hospital.

 

“I carried her for nine months and we couldn't wait to meet her and introduce her to her sisters. It was supposed to be one of the happiest days of my life, just like it had been with my other children, but it became the most traumatic thing I've ever experienced.

 

“Holding her for the first time also became the last time. She was so cold, I’ll never forget what I felt in that moment. It broke me.

 

“When I came home after she passed, I couldn't bear to look at anything. The presents people had bought her, the clothes she was meant to wear and the room we'd decorated for her.

 

“Matthew and my children keep me going. I want to be the best mum I can be for my kids but there are days when the weight of losing Hattie feels overwhelming. Living with that grief while trying to be present for my family is something I struggle with every day.

 

“Not a day goes by when I don't think about what might have been and everything Hattie has missed.

 

“I feel I have to speak out so this doesn't happen to another mum or baby. Nothing will bring Hattie back, but I want to know that changes are being made to help prevent another family from suffering the heartbreak we've been through.”

Baby Loss Awareness Week runs every year from 9 – 15 October.