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Why are babies dying needlessly in NHS hospitals?

Mourning a lost son: Paul and Michelle with their daughters Kitty, aged one, and Lulah, five

May 17, 2011, should have been the happiest day of Michelle Hemmington’s life. Nine days after the due date, her baby had decided to make an appearance.

When Michelle, then 33, was admitted to Northampton General Hospital shortly after 9am, accompanied by her partner Paul Buckley, a teacher, and her twin sister Donna, mother and child seemed set for a normal labour.

But by 11.46 that evening, 33 desperate minutes after he was born, Louie Hemmington Buckley had been declared dead, the 7lb 7oz victim of a shocking catalogue of incompetence and technical failures that starved him of oxygen.

‘I completely trusted that the midwives and doctors knew what they were doing,’ recalls Michelle, now 39, who is a school attendance officer in Northamptonshire. ‘But they let us down.’

Michelle’s dreadful experience is far from unique. In 2015, the Royal College of Obstetricians and Gynaecologists launched Each Baby Counts, a five-year initiative to reduce the number of such tragic events by 50 per cent by 2020.

But the grim conclusion of its review of hundreds of cases, published in June, shows the scale of the task.

Each year ‘between 500 and 800 babies die or are left with severe brain injury’, it found — not because they are born too soon, too small or with an abnormality but, disgracefully, because of ‘sub-standard care’.

The critical question now being asked is why so many babies are being harmed by the health service in a wealthy nation like Britain. According to an NHS-funded review published last year, babies fare worse in the UK than in comparable countries. In Norway, Sweden, Denmark, Finland and Iceland there are 4.3 stillbirths or deaths within 28 days of birth for every 1,000 births; in the UK it is 5.92.

‘The numbers are shocking,’ says Clea Harmer, chief executive at Sands, the stillbirth and neonatal death charity. ‘The death of a baby is profoundly painful for families and for a baby to reach labour at the end of pregnancy and yet to suffer harm that might have been avoided, is devastating.’

Such tragedies also come at a huge cost to the NHS.

In 2016-17, obstetric cases accounted for only 10 per cent of the 10,686 clinical negligence claims against the NHS, but for 50 per cent of the ?4.37 billion cost of those claims — babies who suffer brain damage at birth will often need a lifetime of expensive care.

Two years ago, Catherine Dixon, the former chief executive of the NHS Litigation Authority, said it was time ‘to address the fact that the clinical negligence bill is rising and [that]the only way to reduce it is to invest in safer NHS care’.

In The Law Society Gazette, she wrote: ‘You would think every action would be taken to stop damaging babies’ brains. If the cost runs into billions and the result is untold misery to babies and their families, isn’t it worth investing more to stop this from happening?’ Louie Hemmington was declared dead just 11 minutes after he was born

Unforgiveably, many parents whose babies die or are harmed through hospital errors face years of legal action before the NHS admits it is in the wrong.

After Louie’s death, his parents and their lawyers had a four-and-a-half-year fight before the hospital admitted it had failed them.

The internal hospital inquiry, seen by Good Health, identified a catalogue of 18 avoidable errors, ‘compounded by a lack of leadership and by failures in communication and lack of adherence to guidelines during labour’.

The hospital’s report said Louie and his mother, who was looked after by eight different midwives during her 14-hour labour, suffered from a lack of continuity of care, a failure to start continuous foetal monitoring at the right time and ‘failure to escalate to a consultant obstetrician when an urgent review was required’.

When Louie was delivered, apparently lifeless, there were delays in starting resuscitation, compounded by the fact the Resuscitaire — a machine used to warm and give emergency oxygen to a newborn baby — wasn’t working properly.

After birth, Louie was placed briefly on Michelle’s abdomen while his cord was cut, but her joy turned to dismay when he was whisked behind a curtain. ‘At first we were elated,’ recalls Michelle. ‘Then we heard alarms going off and people screaming for help.’ The horror continued for more than 30 minutes. ‘Finally a doctor appeared and said: “Your son has died.” It was a total shock.’

It was in a bid to reduce such ‘unnecessary suffering and loss of life’ that the Royal College of Obstetricians and Gynaecologists launched Each Baby Counts in 2015.

Its June report reveals the college examined the cases of 1,136 babies who were harmed or died during childbirth in 2015 and unearthed tragic failings.

Sixty independent experts reviewed the local hospital investigations and found a quarter had been done so badly it was imposs-ible ‘to draw conclusions about the quality of care provided’. Each year 'between 500 and 800 babies die or are left with severe brain injury' (stock image)

But of the 727 that were adequately investigated, 76 per cent — 556 babies — ‘might have had a different outcome with different care’. Shockingly, in a quarter of cases, parents didn’t even know their baby’s death was under investigation.

The investigators identified 37 common ‘critical contributory factors’ in the cases they examined, with an average of six in each.

But as with Louie, the most common failings related to cardiotocography (CTG), or continuous foetal monitoring.

Here, mothers are wired up to a machine that continuously displays the baby’s heart rate in real-time, creating a trace that shows all-important variations in heart rate over time.

CTG has been in use for 20 years and, in theory, offers the best chance of spotting problems.

But the Each Baby Counts report found a failure to act upon suspicious readings played a part in 63 per cent of cases, with crucial errors in interpreting the readings in 49 per cent.

An inquest in May into another baby’s death, that of Billy Wilson at Pinderfields Hospital, West Yorkshire, heard from an expert that ‘it’s commonplace’ for midwives to qualify without having training in using CTG.

During her labour, Michelle Hemmington grew increasingly worried about Louie’s ‘erratic’ heartbeat, which she could hear after continuous monitoring was finally started at 9.50pm, just over an hour before he was born.

‘I was told not to worry, everything was fine,’ Michelle recalls. Yet, as the hospital’s internal inquiry revealed, midwives failed to monitor his heart rate properly, before and after continuous monitoring was started.

Michelle pleaded several times for a caesarean. Her fears were dismissed. ‘I knew I couldn’t deliver him on my own without intervention,’ she told Good Health. ‘He seemed stuck and I knew he wasn’t coming out without help.

He was in distress for over an hour, which is why his brain injury was so bad.’

Louie was born minutes after a midwife carried out an episiotomy. An obstetric expert retained by the family’s lawyers concluded ‘that was all he needed when he became distressed, but it came too late’. If the midwives had listened, Michelle believes Louie would ‘have been a healthy baby’.

A spokesperson for the trust told Good Health it ‘admitted Louie should have been delivered earlier and, had that happened, he would have been born alive’.

According to an NHS-funded review published last year, babies fare worse in the UK than in comparable countries

The Royal College of Obstetricians and Gynaecologists says that ‘no normally formed, term baby whose mother labours should suffer death either during or shortly after birth, or suffer a severe disability as a result of an event in labour’.

But if the causes of what it calls these ‘devastating, life-changing events’ are known, why isn’t the aim to reduce them by 100 per cent by 2020, rather than 50 per cent?

The answer, says Zarko Alfirevic, a professor of foetal and maternal medicine at Liverpool Women’s Hospital and a co-principal investigator on Each Baby Counts, ‘is complex: of course we hope to abolish such cases altogether, but we’ve tried to set a target that’s both ambitious and achievable’.

The problem, he says, is ‘we find ourselves . . . in a system where in certain sets of circumstances you have well-trained, experienced people who can still make these mistakes’. Staffing levels, he says, doubtless play a part. So, too, does inadequate foetal monitoring and a range of other factors, including missing antenatal notes and overwhelming case loads that mean staff miss signs a baby is in distress.

Cathy Warwick, chief executive of the Royal College of Midwives, says inadequate staffing is a key factor: ‘There’s no doubt if you do get to the root cause of some of these tragedies staffing levels come into it.’

In 2008, a King’s Fund report concluded that while it was accepted ‘all women should have one-to-one midwife care during labour’, staff shortages meant this was frequently not the case.

The Royal College of Midwives says that in England the profession is short of 3,500 midwives, and recruiting drives are failing to replace those leaving, netting just eight new midwives last year.

As the Mail reports today, staff shortages are being partly blamed for maternity wards having to turn away women in labour. Since Louie's avoidable death, Northampton General Hospital Trust has made 'significant changes and improvements in our maternity services'

A survey the college conducted last year found the main reason given for leaving the profession is, ironically, staff shortages. In Louie’s case, the hospital’s report admitted ‘unrealistic expectations’ by the labour ward co-ordinator, with ‘one midwife expected to care for nine women in two separate locations’.

Despite the hospital’s internal inquiry concluding that the ‘root cause’ of Louie’s death was ‘a lack of effective leadership and a lack of care in labour’, at first the trust denied it had caused his death.

‘We desperately wanted to know what had happened, and for the hospital to learn from its mistakes,’ says Michelle.

But it was December 2015 before the trust admitted liability.

For Michelle, this meant ‘I relived Louie’s death every day for four-and-a-half years, trying to analyse what had happened’. When the legal action ended, ‘we could finally just grieve’.

A spokesperson said the hospital was ‘guided by the NHS Litigation Authority’ (now NHS Resolution), the body that handles negligence claims against the NHS.

Sarah Harper of Access Legal Solicitors, who represented the family, says the NHS ‘routinely denies liability and defends cases such as these’. Sometimes, ‘denials go on for years, which can only serve to add to parental anguish’.

NHS Resolution strongly refuted that it automatically denies liability, saying it has ‘made it a priority to ensure families receive answers as soon as possible’.

Since Louie’s avoidable death, Northampton General Hospital Trust has made ‘significant changes and improvements in our maternity services’.

In 2013, Michelle set up the Campaign for Safer Births with Nicky Lyon, a teaching assistant from Cheshire.

Nicky’s son Harry suffered brain damage due to errors at birth and after a short, difficult life, died of a chest infection in 2009, aged 18 months.

In the past four years, the campaign has been contacted by over 100 parents whose children have been harmed or died in birth — ‘we hear the same things again and again’, says Michelle.

‘That’s why we’re completely in support of Each Baby Counts so these dreadful tragedies don’t keep happening.’

On July 13, 2012, more than a year after Louie’s death, Michelle gave birth to a daughter, Lulah. ‘I was petrified and I refused to go through a natural labour.’ Michelle had an elective caesarean and felt more in control ‘but I was still convinced she was going to die, even after she was born’.

After that, it took Michelle and Paul a little while to pluck up the courage to go through it all again.

Kitty was born, also by caesarean, on July 27, 2016.

Despite the joy the girls have brought, ‘I am not the same person that I was before Louie died,’ says Michelle, ‘and I never will be again.’

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