Monthly Archives

December 2020

Baby Loss Awareness

Lessons learnt

Today the interim report for the inquiry into Shrewsbury and Telford Hospital NHS maternity unit was reported in the news. This has come at a painful time. Nearly three years since Lexi died, reading this and other articles surrounding the investigation magnify the heart breaking experience we had and are still dealing with. 

In the weeks following Lexi’s death Maidstone and Tunbridge Wells Trust promised a full and thorough serious investigation into her death. They came to our home a few weeks after she died, when we were completely broken, to reassure us how they would be “open and honest.” Sadly nothing could be further from the truth. 

The investigation was quite frankly a joke. The woman leading it, who had been to our house and asked us to recount all the painful details of Lexi’s birth and subsequent death, who we were led to believe would be our voice in the investigation, never passed any of the information we gave onto those working on the investigation. She also did not attend the meetings concerning the investigation. Instead the people who investigated only looked to the trusts version of events and the most astonishing part, where they didn’t know what had happened they made assumptions. One of the most heart breaking assumptions I had to read when presented with their report was that I had supposedly forgotten to feed my newborn baby. They had assumed we had been too busy with our other children. How anyone could even think that someone could forget to feed a newborn baby is beyond me. The fact that they wrote this and subsequently submitted it in their report to the coroner for Lexi’s inquest was indescribable. The pain and damage their actions caused can never be undone. Following a 12 page letter we sent to the trust highlighting the failings in the report I received assurances that the report would be revised. The trust was “Sorry it fell short of our expectation.” An expectation that they would have actually investigated the events that led to Lexi’s death. The coroner at the inquest was not able to attribute blame, that is not the job of the coroners court, but he was able to highlight in his statement that I was an experienced mother and my concerns with my daughter should have been listened to. The coroner also thanked me for the evidence I had submitted that showed they had lied in their report. Maidstone and Tunbridge Wells Trust refused to look again at their investigation or report as to them their findings were accurate. Findings that included “there was no evidence of any infections.” Findings that were completely quashed by the experts that spoke at Lexi’s inquest. 

I’m sure Maidstone and Tunbridge Wells Trust hoped we would just go away. Instead over the past few years we have had three independent reports conducted into our daughters care at Maidstone and Tunbridge Wells Trust by an independent midwife, neonatologist and obstetrician. Each of them found failings in the care myself and Lexi had. They heartbreakingly included statements like; “This failure to prompt urgent admission at this phone call fell below the reasonable standard expected of a body of midwives…. On the balance of probabilities if an ambulance had been called, admission would have been by 01:00, Alexa’s condition identified and stabilised and on the balance of probabilities changed the outcome.”  Essentially, if when I had telephoned concerned that my baby was sick I had been listened to, my beautiful Lexi could still be here. This is just one of the catalogue of heart breaking failings identified. 

But where do we go from there? None of this will bring Lexi back to us. We know we did everything we could. But the thing that keeps me from finding any path forward is knowing that nothing has been learnt from Lexi’s death by Maidstone and Tunbridge Wells Trust. No other babies could be saved by the failings that led to her death because they are being ignored. One option available to us was to sue the hospital for negligence. That would only have resulted in a financial sum awarded to us. The thought of it makes me feel sick. Money would not bring our daughter back nor would it help our grief. The solicitors could push for an apology but again a hollow apology would not help save any other babies. A statute of limitations means that you can only bring a negligence claim upto three years after the negligence occurred. That date will surpass next week and we have no plans to rush through a claim. All we ever wanted was for honesty. As the letter I sent to the trust said; “..for us to start grieving properly for our daughter we need to understand everything that occurred. We need to know whether all the processes and procedures that should have been followed were or were not. …Given that our daughter has died I don’t know what else could be more serious to require someone to follow up and ensure that a report is up to standard before presenting it to a family.”

The NHS is an amazing thing, please have no doubt we are very grateful for it. Especially to the staff at Great Ormond Street Hospital who did all they could to help Lexi when she arrived in such a critical state. But there are major failings within some trusts in the way they deal with investigating situations where something has gone wrong. As the inquiry into Shrewsbury and Telford Hospital NHS states “no learning appears to have been identified.” I echo the thoughts of one of the families  mentioned in this BBC article;  “We just wanted to get to the truth.” I wonder how much longer we will be forced to wait and what lengths we will have to go to in order to get the truth.