Baby Loss Awareness Week

The parents of a newborn baby who died aged just 35 hours have asked lawyers to investigate their family’s maternity care.

Ralphie Leach-King-Rhodes was delivered by emergency caesarean at Kettering General Hospital. He was born without a heartbeat and had to be resuscitated.

In the weeks before his birth, Ralphie’s mum, Ruby Leach, of Market Harborough, Leicestershire, had attended hospital several times, including twice with concerns about reduced movements of her baby.

Ruby, who was aged just 20 at the time, had a raised blood pressure reading but wasn’t diagnosed with the condition by staff, an independent investigation found. The report also found hospital guidance wasn’t followed, Ruby’s maternity warning score was incorrectly calculated and she didn’t receive a senior doctor review within the required 15 minutes.

Ruby has now instructed specialist medical negligence lawyers at Irwin Mitchell to investigate whether more could have been done to prevent Ralphie’s death.

Ruby, 22, and her partner, Jacob King-Rhodes, 23, are using Baby Loss Awareness Week to speak publicly about the impact of Ralphie’s death on their family and their search for answers.

It comes after an independent investigation report by the Maternity and Newborn Safety Investigations (MNSI) programme identified a number of concerns regarding the care provided to Ruby under Kettering General Hospital NHS Foundation Trust in the days leading up to Ralphie's birth.

Lauren Mannion, specialist medical negligence lawyer at Irwin Mitchell representing Ruby, said: 

"Ralphie's family are still coming to terms with his tragic death.

 

"When a family experiences the loss of a baby, they're often left with many questions and facing a complex system to get answers. Understandably, Ruby and her family have a number of concerns about their maternity care leading up to Ralphie's birth and we're now investigating further to help provide them with the clarity and answers they deserve.

 

"Nothing can change what happened, but it's important that all of the issues raised by the investigation are fully examined and that any lessons that could improve maternity care are learned."

At 38 weeks and three days pregnant, Ruby attended maternity triage at Kettering General Hospital for the second time with concerns about reduced baby movements and pain around the scar from a previous caesarean section.

After an initial assessment, she was placed in the Trust's orange priority category, meaning she should have been reviewed by a senior doctor within 15 minutes. However, the investigation found she was instead reviewed by a junior doctor more than an hour and 40 minutes later before being discharged home. The report concluded that Trust triage guidance was not followed.

The investigation also found that Ruby's maternity early warning score was recorded incorrectly. Investigators concluded this meant her care was not escalated and she was not reviewed by a senior doctor in line with Trust guidance.

At a routine appointment the following day, investigators found staff did not recognise that Ruby's blood pressure was raised under Trust guidance. As a result, it was not rechecked and no further monitoring was arranged before she went into labour.

Five days later on 30 March 2025, Ruby attended hospital after going into labour at 39 weeks and 2 days pregnant. Staff found Ralphie's heart rate was abnormally low and emergency assistance was called.

Ralphie was delivered by emergency caesarean section and admitted to intensive care following resuscitation.

Tests showed that Ralphie had developed severe hypoxic ischaemic encephalopathy, a type of brain injury caused by a lack of oxygen to the brain around the time of birth. He also developed multi-organ failure.

Following discussions with clinicians, Ruby and Jacob agreed to move Ralphie to end-of-life care.

Ralphie died in Ruby’s arms on 1 April at 1:08, aged 35 hours. Investigators were unable to determine the cause of the interruption to Ralphie's oxygen supply before birth or the cause of his brain injury.

Ruby and Jacob, who also have a four-year-old daughter, Roma, welcomed a baby girl, Rosabella, in March this year.

Ruby, said: 

“When I found out I was pregnant, I was so happy.

 

“When we showed Roma the ultrasound photos and told her she was going to be a big sister, she was so excited. It was a perfect moment.

 

“We were all looking forward to meeting Ralphie. We wondered what he would be like, what he’d enjoy and what he’d grow up to be. We expected to spend our whole lives with him but we had less than two days.

 

“We’ll never forget those precious moments we were able to spend with him, showing him just how loved he was.

 

“I carried him for nine months and he passed away in my arms. That broke me.

 

“The pain I felt in that moment is the kind of pain only parents who have lost a child can understand. It’s something that will stay with me forever. I’ll always be Ralphie’s mum and that will never change.

 

“After we said goodbye to Ralphie, we took him to Rainbows Hospice for Children and Young People so that Roma could meet him and say goodbye to her baby brother.

 

“We would like to thank the staff there for everything they did for us. They were the most amazing people, so kind and compassionate, and we will always be grateful for the support they gave our family.

 

“I’m so grateful for my family. Roma and Rosabella mean the world to me and are the reason I keep going on the days when I don’t feel like getting out of bed. Jacob has also been my rock through everything. It’s been heartbreaking for him too and we’re doing our best to be there for each other.

 

“Moving forward with our lives has seemed impossible for a very long time, but we hope that getting answers might bring us some form of closure.

 

“We may never know exactly why Ralphie died, but we want to understand whether more could have been done and if opportunities to help him were missed.

 

“Nothing can make up for the time we lost with Ralphie, but I’m determined to make sure his death wasn’t in vain. We hope by speaking out we can help save lives and spare families from the heartbreak we've experienced.”

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