'Breach of duty' and errors in woman’s maternity care led to stillbirth of her son

An NHS hospital trust has admitted that a 'breach of duty' and errors in a woman’s maternity care led to the stillbirth of her son.

Stephanie Broadley, 28, broke down after realising her son Beau was already dead when she gave birth to him in May 2018.

High risk pregnancy

Mrs Broadley, who had already suffered a miscarriage prior to Beau’s conception, had contracted an infection during another child, putting her at 'high risk' of miscarrying again.

However, staff at Grimsby's Diana, Princess of Wales Hospital, suffered 'task blindness' and they wrongly believed Mrs Broadley was low risk.

A serious incident investigation found that Mrs Broadley was failed by 'over optimistic' staff who did not check her vitals during labour.

Mrs Broadley, who is a mother-of-six, said: "They just kept telling me everything would be fine and that it was normal, but I knew it wasn't.

"When Beau was stillborn it was absolutely heart-breaking. I just held him in my arms and sobbed, and it is so difficult thinking back now because I feel like I let him down. I was repeatedly saying that I didn't think things were right but now I wish I had been more forceful and loud. The problem is that you place your trust in the people who are there to care for you."

She added: "I repeatedly said that I knew something was wrong and there were three occasions when I was in labour that I reported to midwives that I couldn't feel any movements at all, but no action was taken.

"They didn't increase heart-monitoring, even when I lost blood and it was a funny colour, and they didn't call for a consultant to see me. Midwives just kept telling me everything would be fine and that it was normal, but I knew it wasn't."

Following Beau’s birth, Mrs Broadley says that she held him in her arms and sobbed, wishing she had been more forceful and loud with the staff about her concerns.

'Breach of duty'

Determined to get answers, Mrs Broadley persued a clinical negligence claim, asking solicitors to investigate the circumstances surrounding her son's death.

This led to the Northern Lincolnshire and Goole NHS Foundation Trust admitting to a 'breach of duty' and errors in her maternity care.

Investigations showed staff at the hospital had incorrectly assumed Ms Broadley to be a 'low-risk' case when she went into labour at 36 weeks, as her pregnancy records referenced her having requested a midwife-led home birth earlier on in the pregnancy. However, as two of her previous five children were born before reaching full term she was actually a high risk pregnancy.

The investigation said the references to a planned home birth had altered the 'perception of risk' of hospital staff and led to them “failing to follow guidelines for treating mothers whose waters break before 37 weeks”.

This meant Mrs Broadley was not given antibiotics to prevent infection, and blood screening was not carried out as it should have been. The investigation concluded that this led to 'over optimistic' records which failed to reflect the growing risk to Beau, meaning increased monitoring of his heartrate was not carried out as required.

The report said that key decisions were made 'without actually assessing the patient and not having the full history'.

Failure to escalate concerns

Criticisms were also made of a failure to escalate concerns to a consultant for high risk antenatal patient review, and was a two-and-a-half hour delay after a midwife had requested a registrar review.

Dr Peter Reading, chief executive at the Northern Lincolnshire and Goole NHS Foundation Trust, said: "I would like to offer my sincere condolences to Mrs Broadley and her family for their tragic loss.

"We have carried out an investigation into the care Mrs Broadley received but unfortunately, as legal proceedings are still ongoing, we are unable to comment further on this case."

Helen Budge, a senior solicitor in Potter Rees Dolan's Clinical Negligence team, comments:

This is a tragic case which highlights the importance not just of trusts having guidelines to assess and manage risk in pregnancy, but also having robust procedures in place to ensure that these are followed and that 'optimism' and comlpacency do not creep in.

Helen is a senior solicitor within our clinical negligence team, specialising in fatal clinical negligence claims. If you would like to speak with Helen or any of our solicitors regarding this article or clinical negligence, please call 0800 027 2557 or fill out a contact form via the side of this web page. Alternatively, you can contact Helen directly, here.