A young couple could not wait to welcome their new baby to the world after an uneventful pregnancy. Parents-to-be, Amy and Jamie Harrison, however never got the chance to bring their daugher, Harper, home.
For the little girl was stillborn after a series of failings by The Royal Oldham Hospital staff. Now the hospital trust has admitted that had "appropriate monitoring been carried out" the findings would have led to earlier delivery, "with Harper being born alive".
Staff had failed to look after the mum who was days overdue and she told the Manchester Evening News that she was left alone in a hospital side room "all night" without being checked by a doctor or midwife after being induced. Amy’s baby’s lack of movements went undetected and she died - but could have been saved.
The expectation was that Amy would give birth normally with her husband Jamie by her side and she got through the majority of her pregnancy fine. By May 2020, when Amy was due to welcome her baby, the Covid-19 pandemic had took hold of the country however and circumstances radically changed.
She could no longer be accompanied while giving birth, which she had hoped for, because of NHS hospital social distancing rules. Amy, 30, said: "I’d got to almost 42 weeks - 41 weeks and five days and I’d had no signs at all.
"I was told to ring the hospital and book an induction. I was getting a bit worried that I was way too far overdue."
The couple lived in Bury at the time but only chose The Royal Oldham Hospital because it's where Amy had been born along with her sibling and the children of her friends . They chose the facility for their own baby, believing it was safe.
But "from the moment" Amy called to book in for her induction, she felt "let down" and "left alone". Amy said: "Stillbirth doesn’t even cross your mind, I think as a woman you’re made to feel that going to have a baby is totally normal, it’s actually petrifying when it’s your first baby, and I don’t feel like I had any reassurance. Because of Covid, you just had to be dropped off at the door and go up to the antenatal ward on your own."
Amy explained that hours after starting the induction process on May 18, "nothing was happening" until she started with contractions. Once Amy had been given a painkiller the contractions disappeared. Now 41 weeks and six days overdue, the mum was getting ‘more and more concerned about reduced movements’ of her baby.
The patient asked for the movements to be monitored but was told she had only just had checks two hours prior.
Amy told the Manchester Evening News: "The staff failed to monitor me as they should have done, my contractions were getting more and more intense. I was getting quite emotional because I was on my own and in a lot of pain. A staff member said they would move me and put me in a room on my own - looking back, I think that was the big turning point."
Amy has since found out through investigations that staff had recorded her medical details incorrectly during her stay on the ward.
"They didn’t update my notes properly," Amy said. "It looked like I was a day less overdue. The mistake meant that Amy was never moved to a labour ward for progression.
Amy didn't get much sleep that night as she was getting contractions "every couple of minutes".
"A midwife hadn’t come in all night," she added. "I came out in the night to ask for paracetamol and went back in the room. That was the only interaction I had all night."
There was a change of staff on the ward at the Royal Oldham on May 20. When finally visited, Amy asked why she was having contractions but less movements from the baby and a consultant asked when she had last been monitored.
She explained: "I told the midwife ‘I’ve been in this room since 11pm last night, no one has been in’. Her face dropped. I could tell that wasn’t normal."
Amy says "she could tell straight away something wasn’t right" once a midwife was sent in to monitor the baby. "It took the midwife so long and she was moving the monitor around for ages.
"A more senior midwife came to check, then a sonographer. He was the one who told me."
After two anxious nights, Amy received the heartbreaking news that her baby had died and husband Jamie was called and quickly arrived. "I couldn’t go through the process of giving birth to her naturally. I wanted to have a C-section. I was told ‘most women in your situation do this naturally’, I didn’t care what other people did. The whole process was a nightmare."
The couple were able to spend time with their baby and say staff were "amazing" providing their support - "but it doesn't make the lack of care any better". A few months after their harrowing loss, Amy and Jamie launched a legal case against hospital for its failings.
Amy states that an internal hospital probe was launched, along with an investigation by the Health and Safety Investigation Branch. The Northern Care Alliance, the hospital trust which runs the Royal Oldham, admitted failings with a significant impact on the hospital's maternity service as a whole:
- Staff inaccurately recorded her medical notes
- Amy should have been transferred to a labour ward
Staff failed to monitor Amy and her baby’s wellbeing
- The hospital had reduced staffing during Amy’s labour and was under pressure, but did not communicate effectively
- Multiple physical checks were not carried out when they should have been
'Failure to, adequately or at all, monitor Amy’s and the foetal wellbeing' - including the baby's heart rate during labour
The hospital also found a "culture of acceptance of delays".
Seen by the M.E.N, a letter of response to Amy from the trust said: "But for the alleged negligence, [Amy] would have been transferred to the labour ward. ARM [artificial rupture of the membranes, done to induce labour] and/or continuous monitoring would have taken place. Harper would have been born alive."
The crushing admission went on to say: "On balance of probabilities, had appropriate monitoring of the fetal condition been carried out, CTG abnormalities would have been seen in the period leading up to the fetal demise. This would have led to earlier delivery, with Harper being born alive.”
"I don’t want this to happen to anyone else," Amy said and she explained her story. "Seeing that letter and hearing the hospital admit they could have saved Harper is horrific to hear, but it helps me in a way because until I started getting some answers, I was constantly questioning if I did something wrong.
"Since I lost Harper I’ve met a lot of women who still feel that way because they didn’t go through that investigation process."
Amy wants to encourage other parents that if something does not feel right to them throughout their pregnancy, to ask questions. "I never felt I could especially as a first-time mum.
"You know your own body so well - if you’re uncomfortable, say something. I would like maternity services to look at the care they are providing and ask is this truly a safe environment for mothers and babies because it’s nothing short of life-changing when something goes wrong.
"Losing Harper has had an absolutely catastrophic impact on my life and in many ways, I am a shadow of my former self. Sharing her story is also an opportunity to speak about safety in maternity care and raise awareness of the failures that are causing the deaths of too many babies and how these can be addressed.
"I want people to know about what happened because if it can help to bring about change that can save even one baby, then another family will avoid this horrendous loss. It’s extremely sad that it takes a baby to die for that to happen, rather than it being a given that maternity care will always be safe, but until something changes it will continue to be a lottery as to whether you take a healthy baby home or not."
Dr Chris Brookes, Chief Medical Officer for the Northern Care Alliance NHS Foundation Trust, responded to the M.E.N.: "We again offer our sincere apologies to Mr and Mrs Harrison for the failures in care they experienced during Harper’s delivery. We also again extend our heartfelt sympathy to them for the devastating loss of their much-loved baby.
“An extensive programme of work to continually improve our maternity services is well under way and we remain fully committed to this. Learning from past safety failings combined with listening to and acting on the experience of our patients is critical to ensuring our maternity services are entirely person and family-centred. Progress has already been made as part of our Maternity Improvement Plan, this work being centred on improved obstetric training and fetal monitoring, safer staffing levels, and the recruitment and retention of our midwives."
