Mum lost baby after giving birth at 22 weeks in her bedroom - hours after Blackpool Vic doctors sent her home with painkillers
A young mum lost her newborn baby after giving birth prematurely in her bedroom - just a few hours after Blackpool Vic doctors sent her home.
The 26-year-old woman went to Blackpool Victoria Hospital on the advice of a midwife on at around 10.30am on September 8 2017 after she started having contractions at 22 weeks and four days.
But a doctor there told her she was suffering from a water infection, the symptoms of which could be mistaken for labour, and sent her home with antibiotics and painkillers without doing a speculum examination.
Less than three hours later, she gave birth to a baby boy in the bedroom of her central Blackpool home.
Tragically the infant, Baby J, died a short time later. His inquest took place at Blackpool town hall this week on his parents’ request.
Baby J's dad said: “It was about an hour and a half upon returning home, (mum) shouted from the bathroom and said she felt uncomfortable down below. She couldn’t see anything but she could feel that something wasn’t right.
The dad helped the mum to the bedroom and phoned a midwife at 5.32pm, who called an ambulance.
The mum was placed in category two by the service, which means an ambulance should have attended within 40 minutes.
However, a paramedic was not assigned to the incident until 6.01pm - six minutes after Baby J had been born.
At 5.47pm the dad made another 999 call as an ambulance had not arrived
He was instructed to go outside and wait for the ambulance. During this time, the mum gave birth at approximately 5.55pm.
“I could hear her screaming and shouting ‘he’s here’,” the dad said.
When asked by the coroner what he saw when he went into the room, he said: “His arms and legs were moving. I would hear gurgling noises, gasps.”
The mum said: “I could hear gurgling noises, so I knew he was alive. I kept trying to look at (Baby J), but (dad) laid me down because I was losing a lot of blood and I couldn’t stop shaking because I was so cold.”
The call was upgraded to a category one just before 6pm, as the dad reported the baby had been born and was ‘turning grey’.
A rapid response vehicle was assigned at 6.01pm - with the delay being put down to ‘a resources issue’ - and paramedic James Gorrie arrived at the home at 6.07pm.
He said: “It was a very stressful scene. Emotions were running high.”
He observed that Baby J was showing signs of ‘agnonal breathing’, a natural reflex which happens when a person is not able to draw in enough oxygen to survive.
“There were occassional mouth openings which appeared to be gasps,” Mr Gorrie said.
“They were very, very infrequent. They were not regular or predictable.”
Shortly after Mr Gorrie arrived at the scene, two ambulance crews also arrived, and another rapid response vehicle.
Baby J's cord was cut and he and his mum were taken in separate ambulances to Blackpool Victoria Hospital.
Senior paramedic Wayne Marum said: “(Baby J’s) colour and the transparency of his skin gave the impression that he wasn’t viable for resuscitation.”
However, he ordered that resuscitation attempts should be carried out anyway after he saw the baby give a ‘dying breath’.
Baby J, who weighed just 0.51kg, was taken to the hospital’s delivery unit at 6.30pm, where it was determined that he could not be saved and resuscitation efforts ceased.
His mum said: “I had no idea what happened to Baby J. We were separated as soon as the paramedics arrived. We went to the hospital in two separate ambulances. I kept asking how the baby was, but I didn’t get an answer.”
It was only after she had been treated at the hospital for a blood haemorrhage that she learned her baby had died.
The court heard that, as a result of miscommunication between ambulance and hospital staff, Baby J’s death was registered as a miscarriage, and so no post-mortem examination was carried out.
This was despite a report provided by the ambulance crew noting that Baby J had shown signs of life when he was born.
Blackpool Victoria Hospital gynecologist, Dr Johnson Amu, said the most likely cause of death was extreme prematurity. He said it was ‘highly likely’ the infant would have died even if he had been born in hospital.
“At 22 weeks gestation, the lungs are not well formed, the baby is not ready,” he said. “Once outside the womb, the baby did not have what it takes to sustain itself.”
He said the baby would have to be at least 23 weeks in gestation to have any real chance of survival.
MUM WAS AT RISK OF PREMATURE BIRTH
The inquest heard that Baby J's mum was at risk of miscarriage due to two previous C-sections, a morbidly obese BMI, and an operation to remove a large part of her cervix in January 2017 following a smear test identifying pre-cancerous cells.
She was referred to an antenatal clinic on these grounds in May 2017, and was seen by Dr Amu the following month.
No possible intervention was offered at the time, as it was not available under national guidelines, and she was not warned of the potential risks her operation posed to her pregnancy.
In 2017, having undergone just one loop electrosurgical excision procedure (LEEP) was not considered a risk. This has since changed.
On the morning of September 8, the woman appeared at Blackpool Victoria Hospital showing several red flag signs of premature labour, including abdominal pain and vaginal discharge.
She was examined by Dr Movsar Akhamatove at 2.45pm, who diagnosed her with a suspected UTI after discussing his findings with a senior doctor.
No speculum examination was carried out, which may have revealed that the woman was in fact in labour.
Dr Akhamatove said: “At that time I didn’t think such an exam was warranted.”
But Dr Eric Mutema, head of gynecology at the Vic, said that a speculum examination should have been done.
He said: “A speculum examination on September 8 would not have prevented a miscarriage, but may had meant that the woman did not deliver at home.
“Given that (the woman) was having abdominal pain at the time, there’s a good chance that an examination by speculum would find the neck of the womb was opening, and therefore there would be a good chance of her staying in hospital.”
He said that, by the time the woman appeared at the hospital on September 8, preventing Baby J’s birth would have been impossible.
But had a speculum exam been carried out, his mum may have been spared the distress of giving birth at home.
CORONER TO PEN CONCERNS TO AMBULANCE AND HOSPITAL
Coroner Alan Wilson said: “Baby J was ultimately delivered prematurely at 22 weeks and four days - he did show signs of life. The evidence of his father makes reference to Baby J moving his limbs and fingers, and he references that Baby J was alive.
“The evidence of Dr Amu acknowleges these could amount to signs of life, and I form that view based on the evidence of the father.
“James Gorrie told the court that in his view there were signs of life.
“When Baby J was born he was in extremis and it was highly likely that the condition was not survivable.”
He handed down a conclusion of death by natural causes, with the cause being extreme prematurity.
He said he would write two regulation 28 letters to the North West Ambulance Service and Blackpool Teaching Hospitals NHS Foundation Trust highlighting possible dangers arising from the case.
These included the miscommunication between the ambulance and hospital about Baby J’s condition when he was born, which led to his death being incorrected registered, and a mistake made by the ambulance dispatcher which caused the incident to be incorrectly marked as relating to only one patient, the mum, as opposed to two separate patients in need of individual care.
He said: “It was not fully appreciated that the call for the ambulance was for a need for help for both mum and baby.
“It seems to me that although I’m told that there may have been some individual errors identified... I was not reassured that the ambulance service was reassured that if someone were to ring in these circumstances again, that the recipient of the call would have the training and guidance available to make the right decision, both in respect of the mother and of the child.
“The second issue related to communication. I heard an issue in relation to what information was available to hospital staff prior to Baby J’s arrival. I’m not of a view that this ultimately played any role in the outcome for Baby J, but it seems to me that, although a paramedic’s patient report form was left with the hospital staff, looking at the records from the hospital I wasn’t convinced that that was information that had been considered or appreciated.
“It seems to me that more information was needed abd for that not to be available could place someone at risk in due course.”
Sands, the Stillbirth and Neonatal Death Society, offers bereavement support to parents affected by the death of a baby before, during, or shortly after birth.The charity provides a free national helpline and runs a network of support groups all over the country.
If you have been affected by any of the issues in this article, contact the Sands helpline on 0808 1643332, or email [email protected]