A woman whose baby was stillborn due to mistakes midwives made during labour says she was ‘appalled’ by the lack of compassion shown – telling how she spiralled into depression and how the pain of losing her first child will never fade.
Charlotte Warner, of Streatham, south London, was 23 when she lost her baby boy CJ as midwives failed to notice he was being starved of oxygen during labour. They had stopped taking regular heart readings despite having induced labour with a Propess to start the delivery.
A Serious Incident Investigation into the care provided by St George’s Hospital in London, in May 2018, found guidelines had not been followed, as CTG traces should have been continually checked given Charlotte had been induced, was showing complications of uterine hyperstimulation and was experiencing painful contractions.
As part of a legal case led by medical specialists at Hudgell Solicitors St George’s University Hospitals NHS Foundation Trust admitted that had monitoring been conducted as required, CJ’s deterioration would have been spotted before it became terminal, and steps could have been taken to ensure he was born alive and well.
Hudgell Solicitors is calling for a statutory public inquiry into maternity failings. There are ongoing, serious concerns about maternity services at NHS trusts across the UK. Avoidable baby deaths and birth injuries are at levels not seen for two decades and are often caused by poor working culture, staff shortages and wider systemic failures.
‘Mistakes which cost him his life’
“The pain of losing a baby like we did never goes away,” said Charlotte, now 29.
We’ve just passed what would have been CJ’s sixth birthday, and we are always left wondering what he’d look like now, what his character would be, and what life would be like with him here.
When he was stillborn, we were left feeling completely let down by the staff, and that was before we knew that it had been their mistakes which cost him his life.
Not long after he had been stillborn, one of the doctors made a comment to me along the lines that I’d still be able to have more babies as I was only 23, as if I shouldn’t worry too much as I still had plenty of time to become a mum. I thought that was an appalling thing to say, as it was almost dismissing the devastating impact of losing CJ.
Maternity services centre of damning parliament report
A recent All-Party Parliamentary Group (APPG) inquiry into the birth trauma experiences of hundreds of women across the UK found good care for pregnant women to be ‘the exception rather than the rule’, with ‘poor care all too frequently tolerated as normal’.
It also found ‘shockingly poor quality’ services and highlighted how many women are left feeling ‘neglected, ignored or belittled’ when at their most vulnerable.
The Inquiry considered more than 1,300 submissions from families, including clients of Hudgell Solicitors, together with other relevant parties and was established to identify common features in maternity care that contribute to birth trauma.
The APPG has called on the Government to publish a National Maternity Improvement Strategy, led by a new Maternity Commissioner who will report to the Prime Minister.
Hudgell Solicitors has renewed its call for a Statutory Inquiry into the standard of Britain’s maternity services after the report highlighted the ‘shockingly poor quality’ across the UK.
Read our client Zahra’s Birth Trauma Experience
‘The new Government should make mandatory the recommendations’
Theresa Greenwood, a registered midwife and clinical support executive at Hudgell Solicitors, has worked in NHS hospitals and in the community.
In her role at Hudgells, she uses her extensive knowledge to assist legal teams, producing advisory reports for potential medical negligence claims. She says:
It has become an everyday occurrence that maternity units up and down the country are operating with less staff than they should have, in discussion with colleagues this can often be one third of their workforce missing.
It has been identified by numerous inquiries over at least the last ten years that low staffing levels are key to improving maternity services. The new Government should make mandatory the APPG’s recommendations across all NHS trusts.
There also needs to be urgent and adequate investment to implement these recommendations and surveillance of the impact of the recommendations, so we know that they’re working. That will require a taskforce to measure positive change.
Ms Greenwood, who has also worked as Lead Clinical Governance and Risk Manager within the NHS and on secondment to the Healthcare Safety Investigation Branch, says it is not surprising that childbirth negligence cases now cost the NHS in England £1bn a year.
I am passionate about continually challenging poor standards of maternity training and care, and ensuring lessons are learned to make maternity wards as safe as they possibly can be for mothers and babies.
Staffing levels are getting worse due to many different aspects, maternity care is becoming more complex, women are older and have more complex health histories, the hospitals now induce the labour of more women, and this adds to an increased workload with less staff.
Around 70 per cent of midwives work part-time, many midwives do not want to increase their hours on a permanent basis as they already work more hours for free. In one survey by the Royal College of Midwives (RCM 2024) 50% of midwives were working on average five extra free hours a week.
Whilst most midwives understand you can’t always leave on time constantly leaving work late has a knock-on effect on midwives lives and recovery levels for the next shift “It is a stressful working environment for midwives and women and their families are suffering.
Read our client Beata’s Birth Trauma experience.
‘I wasn’t aware of how things were going wrong’
Charlotte says she was unaware of the developing danger her baby CJ was in during labour, even when midwives didn’t restart monitoring after she’d been allowed a break to get up and walk around.
“I wasn’t aware of how things were going wrong, but of course nor were they until it was too late,” she said.
I’d expressed how much pain I was in several times, but I’d been reassured on a number of occasions that all was as it should be and, as it was my first baby, I just accepted what I was being told.
Then, all of a sudden, a midwife said that she couldn’t find a heartbeat, and I knew instantly that it was bad because there had never been an issue hearing CJ’s heart all the way through my pregnancy.
“I think there’s a lack of compassion, and that is something which is really needed when you go through something like I did,” said Charlotte.
“I suffered from depression afterwards, I was suicidal at times as I couldn’t cope with having lost my baby, and I felt guilty in the moments I did enjoy myself.”
Now a mother to three young children, Charlotte says each pregnancy and birth has brought complicated, mixed emotions that she and her partner Charlie have struggled to cope with.
Apology and damages settlement
The Trust offered a full apology to Charlotte and agreed an-out-of-court-damages settlement after she was represented by Hudgell’s medical negligence solicitor Caroline Murgatroyd, who said:
“There are simply far too many cases where devastation is caused by avoidable errors on maternity wards, and this is being exacerbated with many women then feeling they have been treated with a lack of empathy and compassion.
“In the case of Charlotte there was a devastating failure to properly monitor her baby’s heart rate, meaning midwives missed that it had led to hyper-stimulation.
“Had the required checks been carried out, it was the view of independent experts, consulted by Hudgell Solicitors as part of the case, that baby CJ’s death would have been prevented.
‘Women decide not to have another child’
Ms Greenwood added: “Trauma experiences do have consequences, there’s a knock-on effect. It may mean women decide not to have another child, it may affect their wellbeing and also affect their relationships with a partner or other children.”
“Working for a law firm that specialises in birth trauma we see an increasing number of cases where women and families are suffering.
“We are seeing far too many cases of maternity failings, and it is hugely important that each one is challenged, investigated, and lessons learned.”
Read more: Calling for a Maternity Inquiry
