Lucas was born on the 16th of November 2015 at 35 + 4 weeks. He was 6lb 13oz. Lucas was absolutely perfect. That’s not the opinion of obviously biased parents, that was the opinion of the pathologist who we met several weeks later to find out why Lucas was stillborn.
On the afternoon of Sunday the 15th of November, June was in a great deal of discomfort and distress. She was severely swollen, including her hands and face. She called the local maternity unit and was incorrectly advised by an inexperienced midwife to try over the counter antihistamine medication rather than being invited in for an assessment.
On the evening of Monday the 16th of November, June believed that she was experiencing contractions. We were invited to attend the maternity outpatients department. We carefully packed a bag containing clothes including a little sailor’s outfit which we believed Lucas would be wearing home and some additional clothes for June to wear during her recovery. Lucas’s birth was to be an elective C-section as June was deemed high risk and we merely thought that this procedure would be brought forward on arrival.
On arriving at the hospital, June was diagnosed with pre-eclampsia and Lucas’s CTG was taken as being reassuring. It was pathological. He was in the breech position. CTG disconnected we waited 45 minutes alone in a room to be transferred to the labour suite where Lucas’s heart rate was reassessed as being reassuring by both a midwife and a registrar, when it was still pathological. A ‘wait and see’ birth plan was agreed, however we only learned this at a far later date
Soon afterwards a ‘profound loss of contact’ occurred and unbelievably the consultant obstetrician was not called for until a further 24 minutes had elapsed. Eventually a flurry of activity ensued and I saw our son convulse and writhe on the ultrasound machine which had been brought in. I later learned the he was in the midst of terminal apnea and fighting for his life.
A crash section was called and Lucas was born sleeping at 11.06pm. Delays in notifying the on-call neonatal consultant confined her participation in Lucas’s resuscitation attempt to simply calling a halt to it at 11.24pm.
We left the hospital six days later clutching only a death certificate stating the cause of Lucas’s death as being "unknown". In Scotland, Lucas’s death should have been notified to the Crown Office by the hospital. They never did so. Instead we notified the Crown Office ourselves who then instructed the pathologist who determined that our perfect baby boy had died from perinatal hypoxia, either immediately before or during birth.
A long and protracted process ensued which culminated with the Scottish Government ordering a review, almost a year later, into the management of adverse events within the maternity unit, but only after adverse publicity from the national media. The review team found that the maternity unit required improvement and investment and that they had circumvented their own management of adverse events policy. There was also a low uptake of important training exacerbated by inadequate staffing levels. The Scottish Government further committed to ensuring that CTG training for midwifes would be mandatory and protected and have also committed to looking at the law in Scotland which currently prevents stillbirths from being investigated by the Procurator Fiscal (Coroner) by way of Fatal Accident Inquiry. But the most significant finding for us was that, “earlier intervention could have resulted in a different outcome”.
Although Lucas is not an eligible Each Baby Counts case, we fully support the campaign’s aims and we are sure that there will be an overall trickledown effect on maternity safety as a result.
When we said our final goodbyes to Lucas we made him two promises. The first was that we would find out exactly why he died. The second, was that we would give everything to ensure that no family would have to experience what we had been through. This is why the Each Baby Counts project is so important to us.