A woman had to wait two years for a report that revealed a litany of hospital failings surrounding the death of her unborn baby. Hayley Ryan, 43, told WalesOnline she'd had to wait despite "begging" for answers from Cwm Taf Morgannwg University Health Board (UHB).
The health board runs Prince Charles Hospital in Merthyr Tydfil where Hayley, of Aberdare, had been cared for during her pregnancy with her son Zaiyan. She was 40-years-old when lost Zaiyan at 30 weeks and gave birth to him stillborn on June 12, 2020.
An internal investigation report found there had been six "care problems" at the hospital - including the decision to discharge Hayley from hospital two days before Zaiyan died - and identified eight areas for learning. It also concluded a "root cause" of Zaiyan's death was a missed diagnosis of acute fatty liver of pregnancy, which can cause death or serious disability to a mother and baby.
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"I've been waiting so long for the answers, but then when I got the answers they just destroyed me all over again," Hayley, who has two other children, told WalesOnline. She said she and her family had been searching for answers since about a week after she was discharged from hospital after Zaiyan's death.
"I couldn't get anybody to talk to me. We were phoning and if we managed to get through to anybody, they said: 'We'll get someone to phone you back,'" she recalled. "We even went over to the hospital - but we couldn't get any answers. I can't tell you how many times my mother phoned that hospital in the first few weeks because I was incapable of doing anything."
But when they didn't get any answers for ten months, Hayley decided to get help from a solicitor. "I was at the end of my tether. I couldn't take any more. They made me feel like he didn't matter at all. But he matters to us. It was like he was nothing to them, but he was everything to us," she said.
She instructed medical negligence lawyers at Irwin Mitchell to investigate her care at the hospital - both before and after the stillbirth - and she is prepared to fight her case in court if it goes there. Cwm Taf Morgannwg UHB said it apologises to Hayley and her family "for any anguish caused by delays in communication" and encouraged them to make contact to "discuss their concerns".
Hayley had been admitted to the hospital on June 9, 2020, complaining of vomiting, abdominal pain, lower backache and not passing urine. Her blood test and liver function test results were abnormal and no stomach ultrasound was done for her abdominal pain, according to the findings.
She was discharged the following afternoon without the cause of her symptoms being fully established, the report said. It found it had been "inappropriate" to send Hayley home at this stage when she was still requiring morphine for pain relief.
Recalling being sent home, Hayley told WalesOnline: "He was my third baby, I was 40 years of age, I knew there was something wrong. I've never been so unwell in my life. And there is nothing more frustrating than being dismissed as if there is nothing wrong with you.
"Two independent specialists can't understand how they released me. I should never, ever have been released a couple of days before Zaiyan died. They should have kept me in, because the tests show I was showing signs of something serious, but they sent me home."
She attended a community midwife appointment the following day (June 11). The report found this decision was also "inappropriate", as she should have been advised to attend hospital for an obstetric review and repeat blood tests.
During this appointment, Hayley complained of continued pain and bleeding, but she was not sent to hospital. Her symptoms persisted and she was re-admitted to hospital the following day (June 12).
Within just ten minutes she was told Zaiyan had died and she was induced to give birth to him. She was transferred to intensive care after the delivery because there was concern about her liver function.
A few days later she was transferred to a hospital in Birmingham for further specialist treatment and she was put into an induced coma for four days. When she woke up in Birmingham she was so disorientated that she had no idea where she was and had forgotten she had lost her baby.
She was in hospital for three weeks before being discharged on June 22. Hayley said until a decision is made on whether to settle the matter in court, she cannot move on.
"I don't think I'll feel closure until this is over...I'm still stuck - it's like it's still June 2020. The world has moved on but I haven't been able to. Getting the answers for my son is the only thing I can do for him now - I can't do anything else for him, because I didn't get the chance.
"So the only thing I can do for my little boy is get answers and acknowledgement that he died when he shouldn't have. That's the only thing holding me back right now. When I get that, I feel like I can concentrate on putting my mental health first and trying to move on to being the best mother I can to my other children."
Suzanne Hardacre, Director of Midwifery at Cwm Taf Morgannwg UHB said: "The loss of a baby is deeply tragic, and we apologise to Hayley and her family for any anguish caused by delays in communication by our Health Board.
"Our maternity and neonatal services teams have undertaken a period of significant improvement in recent years, but we acknowledge that there is always still more work to be done. Women and families have always been at the heart of our continuous improvement journey and we are committed to listening to, and learning from, their experiences.
"We continue to encourage Hayley and her family to make contact with us directly so that we are able to discuss their concerns further."
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