Rolf Dalhaug shares his son Thor's story, in support of the Each Baby Counts project.
Our son Thor, and his twin brother Harrison were born on 23 September 2013. A day which should have been the best day of our lives, a day which we excitedly had been waiting for, innocent, without question, our nervous anticipation of the arrival of the family we had so desperately wanted for over 7 years.
In the weeks leading up to the 23 September, Michelle had been diagnosed with Obstetric Cholestasis. A concerning period, but with close monitoring all was well and the decision was made to induce delivery at 37 weeks. Michelle’s waters broke in the early hours and she was admitted into hospital. Later that morning the inducement began and Michelle, Thor and Harrison were monitored closely.
Early that afternoon Thor, who was the engaged twin, had an uncomplicated baseline tachycardia which was classified as suspicious. The induction was not progressing and Michelle’s condition was deteriorating, she was suffering abnormal renal and liver function, and the decision was made to deliver Thor and Harrison by caesarean section. At 4pm we were taken to theatre.
At 4:30pm exactly, Thor was delivered, in a poor condition, completely hypertonic. The silence in the theatre was deafening, at this moment, our world fell apart.
Extensive efforts were being made to resuscitate Thor while Harrison was being delivered, our hearts lifted to his cry, as he emerged screaming to the full capacity of his lungs, a welcome sound to the silence that had prevailed on the room, only previously broken by the murmured huddle of people attending to Thor.
Thor, after an hour of battling for his life, died from his injuries.
It was over a year later, after an extended and arduous inquest, that we learnt the full facts of Thor’s death. An innocent life, our baby boy, Harrison's twin brother, had died through preventable events. Thor's life was not in danger until his attempted delivery.
Michelle and I although devastated by Thor’s loss, went to his inquest with open hearts and minds. As the inquest unfolded and the evidence came to light, we were shocked and deeply saddened by what we heard. Not only was the registrar who delivered him on her first day at the hospital, she was left unsupervised to perform a complicated twin delivery. The procedures the registrar attempted were found to be wholly inappropriate, unacceptable and unorthodox. No attempt was made to follow accepted practice. The coroner's verdict was that Thor died from a major intracranial hemorrhage secondary to the surgeon's manual attempts at disimpaction.
It is also evident from the inquest that the trust failed to investigate this serious neonatal death, and its initial reports and incident investigation policies were found to be inadequate and profoundly flawed. This in itself putting patient safety at risk and a missed opportunity to learn from a serious neonatal death. Only after direct intervention from the coroner and his own expert's report, over a year after Thor's death, did the trust undertake a satisfactory incident report. The coroner was sufficiently concerned by the evidence from the inquest, to issue a “Prevention of Future Deaths Report” to ensure the trust addressed serious systematic and governance failures. This report also questioned the candour and professionalism of the trust's staff.
Thor’s death highlights the importance of continued learning and review of all neonatal deaths, and the RCOG Each Baby Counts project is critical to this.
The loss of Thor has devastated our lives, and we count ourselves amongst the lucky ones as we still have Harrison - we live for him. Every day, every birthday, every Christmas, every first has been a great joy tainted by deep sadness. We will carry the scars of Thor’s loss and the circumstances of his death for the rest of our lives.
Every mother, every father and every family who have to suffer, and live with the consequences of a preventable loss share one thing, a simple thing, a deep and powerful wish that things could have been different - through Each Baby Counts, you have the power to makes things different!
Learning is important, but decisive action from this learning is vital. Trusts, boards and senior management must understand that their roles, their governance and the standards they set are just as critical to life saving care as the medical professionals on the ground. They have an equal duty to the people they serve to do everything in their power to save lives and they must make a personal investment in this - this is their duty. Complacency is not an option. Complacency is costing hundreds, if not thousands of innocent lives. This is not acceptable. The Each Baby Counts project can make a real difference and save lives. I implore you all to give this project your unconditional support and make a personal investment in its objectives.
Rolf Dalhaug has set up the 17dads project. Once fully developed this resource will support fathers going baby bereavement, offering information and support from other bereaved dads. 17dads will also be a collective voice for fathers and families to campaign for safer births and improvements in maternity care and governance. Follow 17dads on Twitter.