A couple have called for a public inquiry at an NHS trust after their two-day-old child died due to what they claim were “systematic failures”.
Preeti and Hrushikesh Joshi, from Leicester, lost their second child, Ansh, after he was born at the Leicester Royal Infirmary (LRI) in April 2022, but claim they were failed “all the way through” by those who cared for them.
The hospital, along with the Leicester General Hospital (LGH), saw the rating for the safety of its maternity care downgraded to “inadequate” by the Care Quality Commission earlier this month.
The University Hospitals of Leicester NHS Trust, which runs both sites, apologised to the family and said that it was learning from the incident.
It wasn't just a freak accident where we lost our son. It was actually a systematic failure all the way through— Hrushikesh Joshi
Mr Joshi, 39, said: “The safeguards were not in place, the red flags were not being picked up, the note-taking and documentation was poor at best.
“The equipment wasn’t available or serviced, which is reflected in the CQC report. They’re marking their own homework at the minute, but it’s happening for real and having read that, it validated what we think.
“It wasn’t just a freak accident where we lost our son. It was actually a systematic failure all the way through.”
The couple opted for a home birth following an uncomplicated pregnancy, but Mrs Joshi was taken to hospital on April 21 last year after suffering severe pain and the baby’s head was found to be high.
However, on arrival, it took 25 minutes to locate the correct ultrasound scanner.
It was later found that Ansh’s head was still high, but Mrs Joshi was bleeding, which led to the decision for her to have a caesarean section.
During the operation, a uterine rupture was discovered, which caused Mrs Joshi to lose more than two litres of blood.
Ansh and Mrs Joshi’s placenta were found next to her diaphragm, with the baby suffering brain damage as he was born. He died two days later on April 23.
His cause of death was later deemed to be a hypoxic ischaemic encephalopathy – a lack of oxygen to the brain before or shortly after birth – caused by a “spontaneous uterine rupture”.
We just fell through the cracks, that's what it feels like, that there was the safety net was just pulled out from under us— Preeti Joshi
The couple, who have been married for 10 years and are both pharmacists, are still dealing with the physical and psychological effects of their loss and are unsure whether they will be able to have more children.
However, they claim their care concerns were not listened to and are in the process of exploring legal options.
Mrs Joshi, 34, said: “The consultant told us that when I was first taken to hospital she thought the baby was already dead, which was never communicated to me.
“I just didn’t ever, at any point, get the sense of urgency from them that something was badly going wrong, there were no alarms raised.
“We just fell through the cracks, that’s what it feels like, that there was the safety net was just pulled out from under us.
“We were left at the mercy of them not listening to the patient, not looking at the whole picture, [and] getting a tunnel vision on one thing they want to focus on.”
Mr Joshi added: “(The trust said) it was a freak accident that happened to you, you were unlucky.
“Well, we weren’t unlucky – (the trust) failed us all the way through, not just once along the way, every step.”
There should be an inquiry just like they're doing in Nottingham, because until people are held to account ... everyone's just willing to brush it under the carpet— Preeti Joshi
The CQC report – which downgraded overall maternity care at LRI and LGH as requiring improvement – said low staffing, issues with risk assessments and infection control problems had caused a “deterioration in the level of care” given to mothers and babies.
It came as an independent review into maternity care in Nottingham remains ongoing, which Mr and Mrs Joshi said should be launched in Leicester.
Mrs Joshi said: “There should be an inquiry just like they’re doing in Nottingham, because until people are held to account … everyone’s just willing to brush it under the carpet.
“There’s a whole systematic failure, people are being let down, and in this day and age with the information we have, the technology we have, people need to be doing more.
“They need to dig deep and not just say ‘Oh well, this happened, let’s publish a report and then move on’ – they need to inquire properly.”
We apologise sincerely to any families that have experienced maternity care which fell short of the standards they should expect— Julie Hogg, University Hospitals of Leicester NHS Trust
Following the CQC’s report, the trust said that staffing was being addressed, as were the other issues raised following the watchdog’s inspection.
Julie Hogg, chief nurse at the trust, said: “We apologise sincerely to any families that have experienced maternity care which fell short of the standards they should expect. We are always willing to meet with women and families and listen to any concerns.
“We follow nationally prescribed processes to understand the reasons behind deaths in our care.
“We know that the number of cases in which care has contributed to death at UHL is very low, and we use the learning from such incidents to improve our services.
“Anyone with concerns about their care is encouraged to contact pils@uhl-tr.nhs.uk in the first instance.”
