A midwife said a pregnant woman was "faking it" when she expressed fears something might be wrong with her baby just hours before the newborn girl died, an inquest has heard.
Tiny Addison Lea Stevenson was born prematurely at 30 weeks and five days gestation following an emergency caesarean but died just hours later.
Heartbroken mum Donna Lea had been admitted to hospital three days earlier with ruptured membranes and was put on the delivery suite as there was a high chance of a premature birth within 48 hours, reports StokeonTrentLive.
An inquest heard that Donna should have been kept on the delivery ward when her care de-escalated, but she was instead moved to the ante-natal ward.
And Royal Stoke University Hospital midwives failed to act on Donna's repeated warnings that she had noticed a reduction in her baby's movements, with the hearing being told that one insisted the mum-of-four was "faking it".
Donna claimed her pleas for an earlier intervention went unheeded
Stoke Sentinel / BPM Media)
In a statement to the inquest, a maternity support worker said she was "angry and upset" that her concerns were not addressed by the two midwives.
She said: "I sent an email to my ward manager expressing concerns regarding an incident during this shift relating to Donna.
"I was angry and upset that concerns had not been acted upon by the two midwives. I informed them on numerous occasions of concerns that Donna had expressed."
The maternity support worker then added that one of the midwives replied to her concerns at the time: "She's faking it…she's just been out for a cigarette, she can't be in that much pain."
However, this contradicted statements provided by both midwives who have said that the maternity support worker did not inform them of the reduced foetal movements until 6.20pm, at which point they acted on the concerns.
An ECG was performed which found that baby Addison was tachycardic. Mum Donna was transferred to the delivery suite for an emergency caesarean but Addison died just a few hours later leaving her parents Donna and Nathan Stevenson heartbroken.
A coroner has ruled there was 'neglect' by Royal Stoke University Hospital staff
Addison died as a result of complications of chorioamnionitis, and the inquest found she could have survived if it wasn't for "neglect".
North Staffordshire assistant coroner Sarah Murphy found that Addison's death was "contributed to by neglect".
She said: "There was a gross failure to provide basic medical attention. I do find neglect. The death was contributed to by neglect." She added: "It is very clear that the hospital trust has looked very carefully at the system errors and the individual errors."
Addressing Addison's devastated parents, Miss Murphy added: "I hope you have been able to see that the hospital has taken this death very seriously. Nobody can bring your baby back but hopefully, if the same set of circumstances happen again, then measures are in place now to try to prevent a similar death. I hope that can give you some source of comfort."
A catalogue of failings led to a delay in this diagnosis, which included:
- Donna was not seen face-to-face by a consultant obstetrician before her care was de-escalated and she was transferred to the ante-natal ward on September 20. The inquest heard she should have remained on the delivery suite;
- When Donna was transferred from the delivery suite to the ante-natal ward, her antibiotics to treat a Urinary Tract Infection (UTI) and an intrauterine infection were reduced from intravenous antibiotics to oral after her results were 'misinterpreted';
- There was a missed opportunity to perform electronic foetal monitoring on September 20 on the ante-natal ward. This would have led to a decision to deliver Addison earlier;
- There was a delay in diagnosing that Addison was suffering with chorioamnionitis.
Donna Brayford, Quality and Risk Manager at the Royal Stoke's Maternity Centre, carried out a root cause analysis review following Addison's death. The trust is now implementing an action plan with "systemic" changes.
Ms Brayford said: "The first root cause was the lack of face-to-face consultant presence on the ward round. We have now made it a mandatory standard that a consultant obstetrician is present in the morning and evening ward rounds in accordance with national guidelines.
"The second is that all mothers whose care is to be de-escalated should be seen by a consultant obstetrician. They will remain on the delivery suite until they are seen by a consultant obstetrician."
Ms Brayford added: "We are also introducing a jump escalation process. When the support worker escalated her concerns to the midwives, she felt like her concerns weren't addressed.
"She could now jump to the next person in charge to escalate her concerns. There are now posters everywhere on the ward to show who you can go to if you don't agree with a decision."
A contributory factor in Addison's death was also a lack of staffing on the ante-natal ward. Ms Brayford explained to the inquest that 26 Band 5 midwives and five international midwives have since been recruited by the trust and a further 20 are expected to be recruited by the end of the year.
Due to the inconsistencies between the midwives and the maternity support worker, a referral has also been made to the chief nurse to decide if further management investigation is required.
A cause of death was provided as 1A E.coli septicaemia, 1B chorioamnionitis and in part 2 prolonged premature rupture of membranes.