The following is a letter from the Chief Executive Officer of Luton and Dunstable University Hospital NHS Trust to the mother of a baby boy whose death the Trust accepted being responsible for through negligent care:
I understand that it has been identified that we failed to promptly recognise changes on your CTG trace and that resulted in your son being stillborn.
On behalf of the Trust I would like to sincerely apologise for this failure and offer our condolences. The Trust takes incidents of this nature extremely seriously and we aim to ensure they do not occur in the future.
I understand that admissions have been made in respect of this in relation to your claim for damages, and I do hope the matter can be resolved as soon as possible.
I’m sure I’m not the only one who finds this letter somewhat disappointing.
Yes, it’s an apology, but it’s one which reads like the apology of someone forced into a corner, and left with no other option.
Where is the true sorrow and regret, and where are the details of what exactly is being done by the hospital to make sure this devastating error doesn’t happen again?
Any heartbroken mother reading this letter – describing the legal process around the death of their baby as a ‘matter’ to be ‘resolved’ – would be furious.
This though, is a genuine letter, sent to one of my clients after going through one of the most difficult and traumatic times of her and her family’s lives.
I’m afraid to say that to get an admission from a hospital trust is as good as it gets. Many choose to steadfastly deny making such errors, even when they are clear cut, making the agony all the worse for the bereaved.
In this case, there could be no denial.
Basic procedures were not followed when there was clear cause for concern over the health of the unborn baby.
The mother had a past history of multiple miscarriages, having three times lost her babies before reaching the age of 24 weeks. Understandably, she had attended at hospital on a number of occasions when suffering from abdominal pains and bleeding this time around.
However, it was on her fifth visit within the space of a month that staff at the Luton and Dunstable University Hospital really let her down – and caused her baby’s death.
Having arrived at some time between 11am and 11:30am with severe back pains, the first entry into her medical notes were made at 12:30. A clinical examination concluded that her examination was unremarkable and that movements were being felt.
However, when CTG monitoring was started 10 minutes later, decelerations in the baby’s heartbeat were spotted, with the hospital later admitting that they were ‘worryingly abnormal’.
Another reading saw a registrar simply record the CTG as ‘suspicious’ – without further action being taken – when in fact the trace showed a dramatically reduced baseline, shallow decelerations and no accelerations.
Failure to carry out emergency birth was negligent
At this time, a decision should have been taken there and then to deliver the baby by emergency caesarean section, and the failure to do so was a clear breach of duty of care.
A senior consultant obstetrician later admitted there had been ‘errors of judgement, delays and confusion’.
The CTG reading was an alarm bell ringing, but instead the mother remained under observation for another hour and when next seen by a specialist registrar, a heartbeat could not be detected and she was rushed to the delivery suite.
At 2:50pm, almost three hours after arriving at hospital, the mother and her partner were told their baby had died.
Errors at the hospital, including the simple failure to correctly interpret the CTG readings – had led to the ultimate loss – the death of a baby who independent medical experts later said could and should have been born healthy.
Pregnancy and birth is a difficult time. It is often a mix of excitement and worry as pregnancy progresses, and both parents-to be and medical professionals need to be aware of all possible dangers, and act appropriately on concerns they have at any stage.
It is crucial for mothers to act quickly on any unusual symptoms, unexplained ill feeling, or sudden changes, such as a lack of movement from their baby.
But when this happens, we expect medical professionals to do their job, fully investigate the circumstances and possible causes, and ensure all relevant tests and treatments are carried when required out to best protect mother and baby.
Sadly, as solicitors handling many cases of birth negligence, we see too many letters from Trusts offering such apologies when serious errors have caused injury or deaths.
We, and the families involved, want to see full investigations carried out, full answers as to what went wrong, and clear changes to procedures and practices to ensure it doesn’t happen again.
We know many midwives and doctors want the same too, with a huge lack in training, and modern equipment, hampering their ability to safely help new life into the world.
Too many lives are being lost before they have started, and as this week marks Baby Loss Awareness Week, we hope the issue of maternity standards and investment in the UK is put under the spotlight, leading to changes being made.