A Midland hospital has apologised to the heartbroken parents of a stillborn baby after dismissing his failing heart rate as a technical equipment glitch.
Staff reckoned a warning message on a monitor checking his vital signs was a ‘technical error’ rather than a sign that the baby was in distress.
Mum Nickie Swinburne was admitted to the Queen’s Hospital in Burton after she could no longer feel her baby move, and was given an emergency caesarean.
Staff unsuccessfully spent around 40 minutes trying to resuscitate her son Theodore.
But a subsequent investigation found staff believed a warning message on a monitor measuring Theo’s heart rate was an error.
This led to significant delays in taking Lichfield mum Nickie for an emergency delivery, and her baby died of ‘a period of terminal asphyxia’.
University Hospitals of Derby and Burton NHS Foundation Trust, which runs Queen’s Hospital, has admitted liability and had issued a ‘profound apology’ to Nickie and husband Andy for the ‘mismanaged labour’.
“I woke up from a general anaesthetic to four words from Andy that will haunt me for the rest of my life: ‘he didn’t make it’,” says Nickie, aged 34.
“This devastation was made worse when we later discovered Theo’s stillbirth had only occurred due to a catastrophic failure in care from our hospital.
“Returning home to a nursery that was ready and waiting, to clothes and toys that Theo would never wear and play with, was heartbreaking.
“Whilst no-one could have prevented what caused Theo’s distress, our son could have been delivered alive within a couple of hours of us arriving at the hospital, had the correct protocols been followed.
"This unforgiveable event has changed our lives forever.”
Nickie and Andy, 35 , phoned the Queen’s Hospital on the evening of July 25, 2016, after Nickie could no longer feel her baby’s movements.
Just a day before she was due to be induced, she was advised to come to the maternity unit, and by 9pm staff began monitoring Theo’s heart rate on a CTG machine.
However, rather than being regularly checked, Nickie was left alone for an hour.
When a midwife finally returned at 10.10pm she saw the ‘warning-pre-terminal’ notice on the CTG and a deceleration in Theodore’s heart rate, but it was assumed to be a technical error.
Twenty-five minutes later a registrar concluded Theodore might not be getting enough oxygen, but still no concerns were raised to Nickie and Andy.
Eventually, 40 minutes after the initial warning message was seen, staff used another CTG machine to check Theo’s heart rate.
Tragically, his heart had started to fail and then stopped altogether.
The registrar was called once again and at 11.35pm Theo was delivered but could not be saved.
A Serious Investigation Report published by the Trust concluded the root cause of Theodore’s death was ‘a period of terminal asphyxia.’
It added that Theodore’s CTG results were ‘sufficiently abnormal’ by 9.50pm, and a registrar should have reviewed them to determine if a caesarean was necessary.
By 10.10pm urgent action was required to perform an emergency caesarean and Theodore should have been delivered by 11pm at the latest.
In the wake of her son’s death, mum Nickie is urging other mothers to trust their gut feelings, and speak out if they think something is wrong with their baby.
“Mothers should trust their instincts,” says Nickie, who works as a teacher.
“I knew something was wrong when Theo missed his ‘wriggle hour’ as we called it.
“It could have been so easy to wait until the next morning when we due to be induced, especially after seeing the midwife that very morning, but my gut told me something wasn’t right.
“Unfortunately as first-time parents, we put out trust in the staff in the hospital and relaxed on the ward after hearing what sounded to us like a healthy heartbeat on the monitor.
“Unbeknown to us Theo was declining and, due to massive errors from staff we had put our full trust in, he didn’t make it.”
In a letter to Theo’s mum and dad, Gavin Boyle, chief executive of the Trust, said: “I am profoundly sorry for the mistakes made and the shortfalls in care which occurred.
“Very clearly, the Trust did not meet the standards of care which you were fully entitled to expect and which we aim, at all times, to deliver.
“I hope it will be of some comfort to you to know we are determined, as an organisation, to learn from the mistakes made in order to minimise the chance of it arising again.”
Eleanor Giblin, specialist medical negligence lawyer at Irwin Mitchell, representing the family, says: “What should have been such a joyous occasion for Nickie and Andy ended in tragedy because staff failed to act on warning signs and missed a number of opportunities to deliver Theodore
“While nothing will make up for Theodore’s death, we join Nickie and Andy in calling on the Trust to ensure it learns lessons from this tragic case so other families don’t have to endure the heartbreak of losing a baby in such unnecessary circumstances.”
Nickie and Andy are speaking about the tragedy during Baby Loss Awareness Week.
“Even though he’s not here, Theo is still very much a part of our family and our lives,” says Nickie.
“It is every bereaved parent’s worst fear that their child is forgotten, so remembering important anniversaries and allowing us to talk freely about Theo makes a world of difference.
“One of our favourite things is hearing our nieces say Theo’s name and talking about him.
“It hurts sometimes, but it’s so lovely they know all about their special cousin.
“We cannot thank our immediate family, close friends and support groups such as SANDS and The Lily Mae for all the help and support they have given us.”
Nickie and Andy, who works as a web developer, have now gone on to have daughter Pippa, who was born this April. #
“Theo is always remembered by us,” adds Andy.
“We take his little sister to visit him at the cemetery and his pictures are proudly displayed in our house alongside Pippa’s.
"We have channelled our grief through fundraising for the charities that have supported us through our journey so far.
“We have found some of the best support for someone who has been through a stillbirth or neonatal death is to just be there to listen.
“Ask us how we are doing and don’t be afraid of upsetting us by saying our child’s name – it is filled with so much love.
"It’s one of the few things that we were able to give our children.
“We would not wish anyone else to have to experience the pain we continue to feel because of how our family was let down by those we put our trust in."
Baby Loss Awareness Week aims to raise awareness of the issues affecting those who have experienced pregnancy loss or baby death in the UK.