A grieving couple have called for lessons to be learned after an investigation found “lapses in care” at a London hospital resulted in the death of their premature twins.
Amber Lincoln and her partner Darren, from Woolwich, found out they were expecting twins in July last year.
Ms Lincoln was placed under the care of a specialist clinic at Lewisham and Greenwich NHS Trust.
Two years earlier, she had undergone an LLETZ procedure to remove cells from her cervix following a smear test which found abnormal cells. The surgery meant her cervix was shorter, leaving her at risk of miscarrying.
As part of her care, Ms Lincoln should have undergone a cervical scan by 16 weeks. However, this wasn’t arranged after the IT system allowed a staff member at an earlier pregnancy scan to select the wrong option. This cancelled an entry on the system that a cervical scan still needed to be arranged for Amber, according to an investigation report conducted by the Trust.
At subsequent appointments she also wasn’t referred to a specialist twin clinic, the report said.
On October 3, Ms Lincoln called a community midwife team raising concerns that she had not received a cervical scan appointment. Clerks were advised to book her a scan by 16 weeks but no appointments were available due to capacity.
A week later, Ms Lincoln attended a routine community ante-natal appointment. A request was made for a consultant review, including a cervical scan as Amber had not yet received an appointment.
Ms Lincoln received the scan at 17 weeks on October 20. An appointment for a consultant obstetrician review of the results was booked for November 2 but Ms Lincoln should have been reviewed that day, the report found.
The November 2 appointment was cancelled and rebooked for November 30 because of an obstetric away day.
At a subsequent routine appointment on November 9, no cervical scan was performed contrary to guidelines. No appointment with a consultant took place, the report found.
Ms Lincoln, who has a 13-year-old daughter, Jada, told the Standard that she “felt like my concerns and the concerns doctors had previously raised connected to my LLETZ weren’t fully understood or listened to”.
“I felt that I went out of my way to raise these at the various appointments I had but it still felt like nothing was really happening and I had to always remind the medical staff or chase up for a cervical scan appointment.”
Ms Lincoln, who had suffered two previous miscarriages since her LLEZT procedure, was admitted to Queen Elizabeth Hospital at 22 weeks’ pregnant on November 22, 2022, after suffering from back pain and contractions for three hours.
Her daughter Anya was delivered breech at 12.20pm the following day and brother, Mael, around 90 minutes later. Both were pronounced dead shortly after delivery.
She said: “When I started with back pain and contractions, I didn’t want to admit it but deep down I knew something was badly wrong.
“Delivering Anaya and Mael was such a traumatic experience. The doctors in the delivery suite did everything they could to save them but sadly they couldn’t. It’s almost impossible to find the words to describe what it was like knowing Anaya had died before Mael was born.”
A Red Incident Investigation report by the Trust, which runs Queen Elizabeth Hospital, admitted that “lapses in care” had resulted in the couple losing their twins.
It added that “the care pathways and system failures that contributed to their loss fall below our expected standards of care and we are very sorry that this happened.”
Ms Lincoln added: “The last few months and trying to come to terms with the events that happened have been awful. Sometimes I wish I had pushed even harder to be heard by the medical staff, but I know that I couldn’t have done or said anything more than I did.
“We loved our tiny dancers, our hearts are broken that we can’t see them. We’re grieving the future that they would have had if they were with us, they’re terribly missed.
“We’d give anything to turn back the clock and for things to be different but we know that’s not possible. All we can do now is share what happened to us to make other parents aware. By speaking out we just hope lessons can be learned as we wouldn’t wish what we’re going through on anyone.”
The couple instructed lawyers at Irwin Mitchell to investigate their care and help them access specialist support.
Hannah Delahoyde, the specialist medical negligence lawyer at Irwin Mitchell representing the couple, said: “This is a tragic case which has left Amber and Darren devastated.
“While the Trust’s investigation report has identified worrying issues in the family’s care, understandably Amber and Darren continue to have a number of questions about the events that unfolded.
“While nothing can make up for their loss, we’re now determined to provide them with all of the answers they deserve.
“In the meantime, we urge the Trust to learn lessons from the issues it’s identified to improve maternity safety for others.”
A spokesperson for the Trust told the Standard: “We are deeply sorry and offer our sincerest condolences to Ms Lincoln and her partner for the tragic loss of their babies. We carried out a full investigation and have made changes to our processes as a result.”
