Mother whose baby was stillborn 2 years ago says lessons 'still not learnt' at two hospital trusts
Video report by Hannah Norbury
A mother whose daughter was stillborn at 37 weeks says lessons still haven't been learnt by two hospital trusts.
Lauren Caulfield's daughter, Grace, was stillborn on 20 March 2020.
An independent investigation showed there were failures during her pregnancy, without which Grace may've been born alive.
Lauren was attending appointments at Leeds Teaching Hospitals Trust before moving to Bradford. After moving home, she was placed under Bradford Teaching Hospitals for antenatal appointments but stressed she wanted to give birth in Leeds.
Lauren said: "In my mind, it's one NHS trust, so they should share records, but in reality that didn't happen.
"So anything I was doing in Leeds, if I was going into hospital, it wasn't being shared with the Bradford side, and vice versa, none of my growth charts, none of my concerns were ever shared between the two trusts.
"They had two completely different records that didn't correlate and didn't recognise when there were problems.
"With my antenatal appointments, the fundal height wasn't being measured properly plotted; so they were either not being plotted at all, weren't being looked at by the midwife, or being taken more than once.
An independent investigation found errors in her care at both Leeds and Bradford Teaching Hospitals Trust, including not plotting her baby's growth.
She added: "So now looking back we can see if they were being plotted correctly, we would've seen that Grace's growth had fallen off of track. If things had of been plotted, it would've been easy to recognise, but because that wasn't done nobody became aware of that.
"It wasn't until I was in labour, that I found out her heart had stopped and she'd died. I had no idea until that point."
The independent investigation found that if problems with Grace's growth had been diagnosed, a plan could have been developed, which "may have altered the outcome for the baby".
An expert obstetrician also looked into the case and concluded on the basis of probability that if Grace's measurements had been taken properly, they would've seen by 37 weeks that there was a problem, and Lauren would have had a C-section.
After birth, Lauren's placenta was misplaced at Leeds General Infirmary.
Tests on the placenta could have provided a possible explanation and helped with future pregnancies, but it was disposed of in error.
Lauren said: "The placenta went missing, so the histology couldn't take place, so we never got any answers as to why this happened."
Lauren is now training to be a midwife at the University of Manchester in a bid to make the changes she wishes she'd seen.
She said: "I couldn't live with myself thinking that other women were receiving the same care. I can't think of a better place to make a difference."
She's also a member of the Maternity Safety Alliance, a group calling for a national inquiry into maternity services.
Emily Barley, from Chesterfield, is one of the co-founders, she said: "I think maternity services are broken. Broken and failing.
"We know from the CQC that over two-thirds of maternity units aren't meeting basic standards of safety.
"We aren't going to give up."
Dr Magnus Harrison, Chief Medical Officer at Leeds Teaching Hospitals NHS Trust, said: "We offer our sincere condolences to Lauren and her family for the loss of baby Grace.
"There was an error which led to the disposal of Lauren’s placenta and could have assisted in understanding why Grace died, and for this we are very sorry.
"We have thoroughly reviewed Lauren’s maternity care and implemented the recommendations outlined in the Healthcare Safety Investigation Branch (HSIB) Report.
"This includes a new procedure for placental histopathology and improvements to our digital maternity system processes, so that there is better communication between different hospital trusts when sharing patient care.
"Our care fell short on this occasion and we remain committed to providing safe, integrated care across our maternity service."
A spokesperson for Bradford Teaching Hospitals NHS Foundation Trust said: “We would like to express our sincere condolences to Grace’s family for their sad loss.
“Following an investigation into the circumstances surrounding Grace’s death we have completed the actions identified, appropriate to our Trust, and are committed to learning from this incident to improve outcomes for all mums and their babies.
“We have also worked closely with Leeds Teaching Hospitals on joint learning points around sharing information between different NHS organisations involved in delivering maternity care.”
A government spokesperson said: "We’re committed to ensuring all women receive safe and compassionate care from maternity services and we’ve made progress in improving outcomes. The stillbirth and neonatal death rates have fallen by 23% and 30% respectively since 2010.
"But we are determined to further improve maternity services. That’s why it is prioritised in our Women’s Health Strategy 2024 and why we continue to support NHS England’s Three-Year Plan for Maternity and Neonatal Services, backed by £186m per year from April. On top of this, as announced at Spring Budget, we will be investing nearly £35 million over three years to further improve maternity safety across England."
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