Expert Medical Lawyers Call On NHS Trust To Prove Their Own Recommendations Have Been Implemented

The heartbroken parents of a two-day-old baby girl who died after midwives failed to recognise her heart rate was dangerously low for almost two hours before she was delivered have spoken about the tragic death of their longed-for daughter.

Imogen Skelcher died at the George Eliot Hospital in March 2011, after being delivered brain dead following mistakes in her birth less than 48 hours earlier. Her distraught parents Samantha Hewings and David Skelcher, were forced to make the agonising decision to switch off her life support and she died in their arms.
 
Despite their grief, the Warwickshire couple made the selfless decision to donate Imogen’s organs so her ‘needless’ death was not completely in vain and she helped to save other lives.

They instructed medical law experts at Irwin Mitchell to help find out what went wrong and why, and are speaking out for the first time after George Eliot Hospital NHS Trust admitted full responsibility for Imogen’s death. The Trust has now agreed to pay a substantial five-figure settlement to fund grief counselling and cover care costs after the couple both suffered from severe depression.

Samantha, 27, from Atherstone, had an emergency caesarean with first son, Jack, in 2009 but was told she would be fine to have a natural delivery with her second child. However, midwives failed to recognise Imogen’s heartbeat fluctuating on the heart monitor and continued to induce the labour which culminated in Samantha suffering a ruptured uterus and Imogen sustaining severe brain damage.

Sara Burns, a Partner and medical law expert at Irwin Mitchell’s Birmingham office representing the couple, said: “Samantha and David are distraught by the loss of their daughter and it is something they are unlikely to ever truly come to terms with.

“They have both suffered severe depression as a result of what they experienced during Imogen’s delivery and their grief has understandably taken its toll on other areas of their lives. David’s father is a funeral director and he took the responsibility of burying his own granddaughter, which was obviously heartbreaking.

“Sadly Samantha and Imogen’s care was unacceptable, not least because Samantha had had a previous caesarean section. There was a failure to properly induce her labour which was carried out without Consultant input until the very end.  Even then there was a delay in making the critical decision to carry out an emergency caesarean section.  By the time a decision was taken Samantha’s uterus had ruptured and the damage had been done.

“An independent report obtained by the hospital trust following Imogen’s death highlighted a series of critical errors made by midwives and included recommendations to ensure the same mistakes cannot be made again.

“It is absolutely vital that the Trust now proves these recommendations have been implemented to give peace of mind to current and future patients that their safety is the top priority.”

The independent report compiled after Imogen’s death, found:
• There was a failure to develop a clear individual management plan for Imogen’s birth
• There was a failure to identify it was a high risk pregnancy and delivery given Samantha’s first birth
• There was a failure to review Samantha’s planned care as complications surfaced
• There was a failure to recognise and act upon Samantha’s deteriorating condition
• There was a failure to recognise and communicate the urgency of the emergency situation
• There was poor communication throughout the delivery
• Approved guidelines were not followed

Recommendations include continuing education for labour ward staff on heart monitoring, better communication between midwives and doctors, more thorough note taking and tighter guidelines introduced for natural births following a previous caesarean.

Samantha, who has since given birth to another baby boy, Alfie, said: “We were so excited for Imogen’s arrival and for Jack to have a little sister. Everything had gone to plan during the pregnancy and I felt like I was in safe hands because Jack was delivered at the same hospital.

“After I was induced and went into labour the pain was far worse than anything I had experienced before and I knew something wasn’t right. I was so distracted with the pain that I didn’t notice the heart monitor and how low Imogen’s heart rate was dropping when I had a contraction. As soon as I realised, I called a midwife and she notified a doctor and I was rushed for a caesarean section.

“Making the decision to turn off the life support machine was the hardest thing we have ever had to do. We just couldn’t believe what was happening to us, it felt like a nightmare.

“David and I knew straight away that organ donation was something we wanted to arrange. Our hearts were breaking about Imogen but it gave us some strength to think we might be able prevent other parents feeling the same pain of losing their baby.

“We’re still distraught, but, if by sharing our story we can make other parents consider organ donation when the worst happens, as well as prevent the same mistakes from happening again, then it gives us some hope that Imogen’s death was not completely in vain.

“Nothing can turn back the clock, but we just hope that the hospital trust has learnt lessons so the same tragedy won’t happen again.”