Caroline Tully shares the story of her daughter Clara, who died shortly after birth.
In March 2014, at 37+1, I went into labour with our first daughter Clara. My waters didn’t break but we waited until my contractions were 2 minutes apart before setting off to the hospital. On arrival basic checks were carried out and we were advised to go home as labour with your first baby can take up to 24 hours. My daughter’s heartbeat was listened to once.
We were concerned and recorded the increasing frequency and length of each contraction ourselves. We did not feel we were listened to. We said that we didn't want to be sent home but the midwife was determined she knew best and it took us 25 minutes to struggle back to the car. Within an hour we were back at the hospital and our daughter was born within minutes.
There was no sound from Clara after she was born and emergency procedures were then followed. We were told after 30 minutes that resuscitation was unsuccessful and that Clara had been stillborn.
We were advised later by hospital staff that Clara’s death was “just one of those things”. At this point we were not aware that the hospital had issued a Safety Alert after Clara’s death to encourage CTG monitoring for all mothers presenting in labour until an investigation had been carried out.
External investigations revealed that I had been incorrectly classed as ‘low risk’ and placed under ‘midwifery-led care’ from the beginning; this inaccurate risk assessment remained throughout my pregnancy and assessment whilst in labour.
Some of the other failures identified were:
- Family history of sister having pre-eclampsia that had not been taken into account
- Lack of continuity of care; we only saw the same midwife once
- Incorrect gestational calculations
- Inability of community midwives to access IT systems
- Failure to follow-up on hospital tests when a midwife suspected pre-eclampsia at 34 weeks
- Inappropriate discharge when presenting in labour
- Delay of 25 days in counselling being offered
- Delay introducing GROW charts
Following my own investigations I found records made by 5 different staff members referencing hearing a heartbeat immediately before delivery and a faint heartbeat 28 minutes into resuscitation. This prompted the chief coroner to approve an inquest to be held by the coroner’s office, which revealed more failings and concluded Clara had indeed been born alive. The coroner’s inquest, we believe, prompted quick action to meet recommendations made by other investigations.
There were 9 other unexpected deaths within the maternity department prompting a review to be commissioned by the Trust and conducted by the RCOG. I am relieved to say the hospital has been deemed safe by the RCOG and improvements have also been confirmed by the coroner.
As a family we are devastated that there were many missed opportunities at various points in my pregnancy and labour that could have saved Clara’s life. I will never get to see my daughter grow and flourish in life, but I am determined her short existence will count towards positive changes by way of highlighting the importance of coroner’s inquests and works done by charities such as the ‘Campaign for Safer Births’.
I believe the Each Baby Counts project to be essential in raising awareness and working towards ensuring avoidable deaths are minimised. I worry as a country we lean too much towards midwifery-led care without having the resources, adequate cross-training in all areas of midwifery and directional support that is provided by obstetricians. The more knowledge that is gained through identifying possible care issues, the faster these issues can be addressed and lives saved.
Grandparents count too
Marie Kemp, Clara’s grandmother, shares her story.
I am Clara's Nanna. I grieve for my daughter Caroline's loss and also grieve for the loss of my grandchild. I try to be strong for Caroline and am very proud of what she has achieved in the wake of Clara’s passing, but still struggle with my own pain. I have still not got over the shock of losing Clara and I doubt I ever will. Whenever I see my other grandchildren I am reminded that one of them is missing.
I still have flashbacks of the phone call from Caroline in March 2014, telling me that she had lost Clara. I remember the hushed ward, the midwives who could not face us, the consultant’s tone of voice and the little body wrapped in a shawl. It’s still surreal.
I myself lost a baby called Charlotte aged three weeks in 1991 due to Patau’s Syndrome. I believe I received better care and counselling from the NHS before her birth and afterwards than Caroline had in 2014. Losing Clara seemed to be far more shocking for me than losing Charlotte due to the mistakes made in Caroline's care. I think some midwives are tending to ignore expectant mother’s concerns. After all, even a first time mother listens to what her body is telling her.
My experience with our local hospital has taught me that grandparents and family feelings are being ignored. Empty condolences mean nothing when a family is shocked and bewildered.
I believe the Each Baby Counts campaign is a fantastic idea. Stillbirth and baby death has traditionally been a taboo subject, hidden under a blanket of secrecy. This needs to change. The RCOG will now be able to offer help to pinpoint where maternity services need assistance.
Unfortunately this has come too late for my granddaughter Clara but I know she has played a part in making this happen. To know that this little lost girl, with her Daddy's snub nose and her Mummy's lips has made a difference provides me with some comfort. She is, and always will be Nanna and Granddad’s grandchild number 4.
Reflections from the Each Baby Counts team
The Each Baby Counts team and the RCOG are determined to hear the voices of women whose births have been touched by tragedy. The story shared here is a very personal view of a bereaved mother and grandmother who lost a child in circumstances which can only be described as heart-breaking.
When analysing these events in the cold light of day, we have to ensure that all relevant professionals are held to account, and individual lessons are learned, but at the same time look at how the systems we have created in maternity may have failed. This is the concept of a “just culture” espoused by Sydney Dekker in his excellent book  as well as his comment on the Mid-Staffordshire enquiry . A good serious or adverse incident report will address systematic failures and make system-level recommendations without vindictive or unjust persecution of staff involved.
The recent publication of NHS England’s SUI framework, gives clear advice on how to involve patients in the process of investigation  and if followed, will hopefully go some way to preventing more families feeling the emotions described in this story. It is always important to remember that all staff groups are capable of falling down, of underachieving and failing to perform as expected. None of us come to work in the NHS with the intention of causing harm; we must be accountable if we do, as must the system we work in.
 Dekker S. Just culture: Balancing safety and accountability: Ashgate Publishing, Ltd.; 2012.
 Dekker SW, Hugh TB. A just culture after Mid Staffordshire. BMJ Qual Saf. 2014; 23 (5):356-8.
 Durkin M. NHS England Serious Incident Framework. NHS ENGLAND; 2015.