Mum sent home with sick baby twice by maternity unit - and then her son died
A mother was sent home with her sick baby twice by a maternity unit and he died hours later, an inquest heard.
Nicole Ditchfield told her son Luca's inquest she was made to feel she was being "over-dramatic" during repeated calls and visits to a hospital maternity unit when she went into labour. Luca died at Tameside General Hospital following a severe brain injury, which the family blame on a lack of oxygen before birth and alleged poor attempts at resuscitation.
An inquest into the tragedy heard that twice Nicole visited the maternity unit but was told to go home and that, as her contractions grew stronger, she started being sick and complained of bleeding, she made 13 unanswered phone calls to the unit.
Baby Luca with mum Nicole and father Jack (Men Media)On her third visit to the unit, midwives struggled to detect a heartbeat and Luca was delivered following an emergency Caesarean section. The infant was left with a severe brain damage due to a lack of oxygen and his devastated parents took the heart-breaking decision to withdraw him from life support. He died on January 24, 2022, in the maternity unit of the hospital, the day after his birth, reports Manchester Evening News.
Miss Ditchfield, a business administrator from Ashton-under-Lyne, Greater Manchester, first attended the maternity unit on May 30, 2021, with her partner and father of the unborn child, Jack Yates, and the pregnancy 'progressed normally' apart from mum catching Covid in December, although she recovered.
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The parents told Stockport Coroners' Court on Monday they had a "reassuring" visit to the maternity unit on January 7 when a scan showed Luca, then at 39 weeks gestation, was 'moving well' and the unborn infant was said to weigh 7lb and 1oz.
"I felt well in myself," said Miss Ditchfield. The pregnant mum called the unit on January 12 when she spotted 'light pink spotting' and she was told to get back in touch if it got any worse. Miss Ditchfield attended the unit for a routine appointment on January 18 and was booked in for an induction on January 24.
But at 6.45am on January 22 she called the unit as she thought she had gone into labour as she was experiencing contractions. She said she was advised to try to sleep or have a bath and take paracetamol for the pain, the inquest heard.
Miss Ditchfield called the unit again at 1.50pm as the contractions were getting worse and said she had one during the eight-minute call.. She said she was advised she was 'not in active labour' and not to call back until the contractions were happening every four minutes.
She called back again and this time she was advised to come into the unit as she had reported blood loss on this occasion. At the unit she was advised she was dilated 3.5 to 4cm and, having 'listened' to the baby's heart rate, staff reported 'everything's fine' with Luca, Miss Ditchfield told the inquest.
She was sent home with pain relief medication and said she was told to report back only when the contractions were coming every three minutes for at least an hour.
At home, Miss Ditchfield said she managed to get two hours of 'broken' sleep but was woken by the pain of her contractions. She said she was also being sick and could not keep any food or fluids down.
She said she called the unit again at 9.42pm and told staff that she was being sick, thought her waters had broken, that she was 'still bleeding' and the contractions were painful.
Miss Ditchfield went into the maternity unit a second time and she told the inquest 'the midwife did not seem to believe my waters had broken' and thought instead she had urinated. She said she wasn't asked about blood loss or the amount of fluid she had lost when she explained she had been sick.
She told the inquest doctors then examined her and concluded there was 'no evidence' her waters had broken and that there was still water around the baby's head.
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"I was happy to stay on the hospital but I was never given the option to stay and I was told to go home," said Miss Ditchfield. She said that once home she vowed to wait until she was experiencing contractions every three minutes before calling the unit again, as advised, as she didn't want to 'bother the midwives' even though by then the contractions were 'very painful'.
The following day, the inquest heard Miss Ditchfield made 13 unanswered phone calls to the maternity unit as she became increasingly concerned. The 14th was finally answered at 2.45pm.
"The phone just rang and rang. Not an engaged tone, it was just not getting answered," she said. Miss Ditchfield said that when she did get through she was told she needed to be put through to triage but nobody answered at triage either.
"Eventually I got through but I was told it didn't seem like I was in active labour," she told the hearing, adding: "I was made to feel I was being over-dramatic."
The inquest heard that Miss Ditchfield attended the maternity unit where she reported a 'shocked' midwife found she was dilated by 10cms, and went to another midwife for a second opinion.
Miss Ditchfield said a midwife tried to record the baby's heart rate and she could see 'numbers dropping on the machine'. She added that she could not recall much after this point although she said she was not under the impression there was 'any urgency or concern for my baby'.
Miss Ditchfield recalled staff struggling to detect Lucas' heart beat and crying when she was told she needed an emergency Caesarean section. She said staff were 'rushing around'.
Her partner Mr Yates told the inquest he remembered 'people running round Nicole in a manic fashion' and that everyone left the room and he was left 'not knowing what was happening'. He said a member of staff told him later that 'baby was out but was struggling to breathe'.
Later he was taken to a room where he could see Nicole was sleeping and tubes were coming out of Luca although he still didn't realise the 'severity of the situation and that he might not make it through the night'.
"I was shocked by how ill he looked," he said. He said he was told Luca has suffered brain damage due to a lack of oxygen and that it had taken 40 minutes to resuscitate him.
Mr Yates said he recalled feeling 'grateful' that so long had been spent resuscitating Luca and that he had been assured the baby's collapse had been 'inevitable'.
Miss Ditchfield recalled waking up and seeing her mother 'visibly upset'. "I asked mum where my baby was and she didn't answer. She started crying," said Miss Ditchfield.
She said she also recalled feeling 'grateful' at the attempts to revive Luca and even 'making a speech' to medics saying how thankful she and her partner were.
The doctors apologised and told her they "could not do more". The couple made the 'awful decision' to remove Luca from ventilation and he died, the inquest heard.
Miss Ditchfield said she was informed there had been an investigation by the hospital and was not told that anything had gone wrong. She said she felt guilty that the collapse may have been something she had caused.
She said it was only when she saw the hospital's report she understood the 'severity' of alleged failings and that she sought legal representation. "We've found it very difficult to talk about what's happened... My first reaction was that the hospital lied to us," she said.
The inquest heard that a report by the Healthcare Safety Investigation Branch (HSIB) uncovered a number of alleged failings at the maternity unit.
Among the alleged failings was that staff at the unit had a 'local perception' that a mother's contractions had to be once every three minutes for at least an hour before 'established labour' could be diagnosed. This 'delayed' the Nicole's diagnosis that she was in established labour, according to the HSIB. Miss Ditchfield has since had another baby. The inquest is due to last all week.
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