Jade was full term in her pregnancy when she started to have mild contractions. The next day, she noticed that her baby was not moving as much as he normally did and telephoned the Maternity Triage team at around 2pm. She told them of her contractions, and that she was worried about reduced fetal movement. She was told to increase her fluids and food intake and call back ‘this evening’ if she remained unsure.
Sadly, this was the incorrect advice and was in breach of national guidelines. Jade should have been told to attend the maternity unit immediately, or at the very least she should have been advised that if normal movement was not felt within 2 hours, to attend the maternity unit urgently at that point. Jade was not informed of either of those things, and so remained at home.
Jade called back at 9.30pm advising there was no improvement, yet again she was told to remain at home and have a bath. Jade was so concerned that at 11pm she phoned again and told them she was coming in with her partner, Darren.
On arrival, it soon became apparent that her baby was in distress and Jade was transferred immediately to the labour ward and the obstetrician was called to assess her. There were attempts to listen to the fetal heart rate, but there was confusion as to what was the baby’s heartbeat and what the mother’s. Whilst a decision was made to proceed to an emergency caesarean section, there was delay caused by the decision to wait whilst the heartrate could be observed.
Jade and Darren’s baby Eddie was finally born by caesarean section but sadly had no signs of life. He was transferred to the neonatal team who did everything they could to save him. Whilst a heartbeat was finally detected, his injuries were too severe, and he died in his parents’ arms that evening.
There had been problems with the placenta which was most likely the cause of his reduced fetal movement the day before he was born, and he had deteriorated resulting in acute starvation of oxygen to his brain during the last stages of labour.
Our investigation
Following obtaining expert evidence, we submitted a Letter of Claim to the Hospital. They made early admissions that the advice they gave Jade over the phone was wrong. They accepted that if the correct advice had been given, Eddie would not have died. The Trust sent Jade a Letter of Apology and explained that as a result of Eddie’s death they had updated their guidance for the management of reduced fetal movements to ensure that mothers are given advice in line with national guidance and can access prompt referral when there are episodes of reduced fetal movement.
The Trust did not comment further on the treatment Jade received when she actually attended hospital however our evidence was that if the delay caused by the treating clinicians had not occurred, Eddie would still have survived. Whilst not admitted, this was not denied by the Trust.
A settlement was achieved early, and without the need for legal proceedings. Given what the family went through, Jade was an inspiration in how she coped. However, their lives will be changed forever due Jade’s concerns not being listened to.
Lessons learned
There is nothing that can be done to change the tragic loss of Eddie, and that is something the family will have to live with forever. However, it is of great importance to the family that the Trust not only accept what happened was wrong, but that patient safety is improved so it doesn’t happen again to others. Whilst the Trust have indicated that they have updated their Guidelines in respect of advice around reduced fetal movement, it is not clear what on the ground has changed.
The family had to wait for 5 years for Eddie’s Inquest. The Coroner found many failings in the care provided by the hospital but was positive that the Trust had learnt a number of lessons from what happened and amended their procedures to avoid what happened from being repeated.
Jade was reluctant to seek advice initially, however said “I’m so glad I decided to seek legal advice to investigate what happened to Eddie. I was recommended Claire Leslie at Enable Law and she has been the best ever, guiding us through the process and supporting us all as a family all the way through. Big big thank you to her and her team. It’s really important to make sure you are heard and that lessons are learned.”
