Parents who have lost babies during birth and pregnancy due to alleged failures by NHS trusts are calling for a new national review of maternity services after a series of scandals.
As details emerged this week of the death of baby Giles Cooper-Hall at Derriford Hospital in Plymouth, those who have experienced similar tragedies said something must now be done nationally so other families are not faced with same heartbreaking circumstances.
“One death is one death too many” Rosalind Levine told i.
“We don’t need to have 15 or 20 before they make changes.”
It comes after the Ockenden Review found “repeated failures” occurred at Shrewsbury and Telford Hospital NHS Trust maternity services and now Nottingham University Hospitals maternity services are the subject of an independent review.
‘I wanted them to put their hand up and say we made a mistake and we are sorry’
Warning: This article contains an image that some may find upsetting
Ms Levine, from Borehamwood, Hertfordshire, went through five rounds of IVF before she eventually conceived a much-longed-for first child on her sixth round in 2011.
During her pregnancy, she suspected she had gestational diabetes and said she raised the issue at the midwife-led Edgware Birth Centre on a number of occasions but it remained undiagnosed and untreated.
She was 11 days overdue when she went into labour on 14 April 2012.
Worried about the lack of movement from their daughter, Ms Levine and her partner Maxie Allen made seven calls to the birth centre.
“They said don’t worry about it, babies don’t move much during labour”, she said.
When the couple went to the birth centre, a scan revealed there was no longer a heartbeat for their baby.
Ms Levine was then sent to Barnet Hospital, where Alexandra was stillborn on 15 April 2012.
After giving birth, Ms Levine said blood tests revealed she was diabetic which she said puts mothers at greater risk of stillbirth.
“Unfortunately, they did not diagnose me with diabetes or tell me to go to the hospital when I said there was no movement,” she said.
The family took legal proceedings against the hospital trust and a settlement was reached.
“I wanted them to put their hand up and say we made a mistake and we are sorry,” Ms Levine said. “There’s no accountability with stillbirths.”
The television producer, 43, said it made her “feel sick” to discover other parents had lived through similar experiences after the publication of the Ockenden report.
“Nobody is joining the dots, nobody is looking at the whole picture,” she said.
A spokesperson for the Royal Free London said: “We would like to offer Rosalind Levine and her family our deepest condolences and to once again apologise for the care provided to her and her daughter Alexandra at Edgware birth centre.”
‘I can’t help what happened to my daughter but I hope her legacy can help other babies live’
Lianne Alizadeh, whose baby daughter Aaliyah died 26 weeks and five days into pregnancy, said differences in maternity care across the country mean expecting mothers face “a postcode lottery” of care.
The medical student and her husband Mohamed, from South London, had been expecting twins but lost one of the babies at 10 weeks. By about 20 weeks, Ms Alizadeh “was experiencing reduced movement”, from her second twin.
For weeks, she said she was in and out of triage at her hospital, raising concerns about her baby’s lack of movement, but said she was sent home without being scanned.
After a CTG to measure the baby’s heartbeat in July 2021, she was told everything was fine but when she woke the next day she couldn’t feel her baby move.
The 31-year-old returned to the hospital where she said she finally had a scan and was told her baby’s heart had stopped.
After that, she said: “I was left in a room on my own for 12 hours because I was no longer a priority.”
Her daughter Aaliyah was stillborn on 10 July at 4.30pm.
Legal proceedings are currently ongoing between the family and the hospital trust involved.
Ms Alizadeh has founded the charity Aaliyah’s Angel Army, which raises funds to provide private scans to prospective parents who have concerns about their baby.
“I can’t help what happened to my daughter but if her legacy can help other babies live then that is good”, she said.
As part of her charity work she said she has been contacted by women nationwide who have said “this is happening to me”.
“I think there needs to be a nationwide review not just local inquiries”, she said, “For me one death is too many.”
One of the problems she highlighted was a piecemeal approach to maternity services, with NHS guideline all trusts must follow and then recommendations which trusts can choose to adopt or not.
“It’s very much a postcode lottery,” she said “We have fatal outcomes because they [the hospital trusts] are all on different pages.”
‘There’s an awful lot of learning from these deaths, which we are just not doing’
Michelle Hemmington had a “normal, healthy pregnancy” and went into labour at 41 weeks. “Really from that point on the mistakes were made,” she said.
She arrived at Northampton General Hospital around 9am on 17 May 2011 and said she was told the unit was very busy and so was placed in a bath initially.
Then she was moved to triage, where she said she spent five and half hours of her labour without being seen or given pain relief until her sister raised the alarm.
“When I was examined, I was 8cm dilated and that’s when I was taken to the labour ward,” she said. A heart monitor was attached to her unborn baby because she said he was becoming distressed.
“The heart rate didn’t seem right to me but I was told not to worry,” Ms Hemmington said. Just after 11pm, she was given an episiotomy and Louie was born at 11.12pm.
“We were told he would need a bit of oxygen,” she said. “He was on the resuscitaire [incubator] behind a curtain for 30 minutes.
“Then this man appeared from behind the curtain and said I’m sorry your son is dead.”
The family had to register Louie as stillborn, which Ms Hemmington disputes. “There must have been signs of life for them to try to resuscitate,” she said.
A serious incident report compiled by the hospital highlighted 19 separate failings in Ms Hemmington’s case but it took four and a half years of litigation before the trust admitted negligence leading to the death of Louie.
In 2013, the education officer, 44, co-founded the Campaign for Safer Births with another parent Nicky Lyon, whose son Harry suffered brain damage because of a lack of oxygen during birth.
They work to raise awareness of birth injuries and stillbirths, campaign for improvements in maternity services and call for inquests for stillbirths.
“At the moment, these baby deaths are completely hidden, with inquests it is in the public domain and on public record,” Ms Hemmington said.
Northampton General Hospital’s Medical Director, Matt Metcalfe, said: “We recognise mistakes were made in the maternity care of Ms Hemmington in 2011 and we again offer our deepest apologies and sincere condolences for the loss of baby Louie.
“Since Louie’s death in 2011 we have made significant improvements to maternity services based on an expert review and we now include a clinician from an external organisation as part of our maternity investigation procedure into serious incidents.”
A private members bill has passed through Parliament for coroner’s inquests to be extended to stillbirths but progress has stalled since the pandemic.
Having an inquest would mean a coroner is more likely to spot trends in baby deaths for a certain trust and could make recommendations to improve safety, Ms Hemmington said.
She said a nationwide review of maternity services, allowing individuals to contribute, would be beneficial.
“We, as bereaved parents, cannot continue to hear and accept that ‘lessons will be learnt’ as this just feels like lip service,” she said.
“There’s an awful lot of learning to do from these deaths, which we are just not doing.”
NHS England and NHS Improvement are working with the Department of Health and Social Care to implement the 15 “immediate & essential actions” identified in the Ockenden report. Every NHS trust is required to consider and act on the report’s findings.
An NHS spokesperson said: “It is clear that there is much more work to be done to improve maternity services and the NHS has already taken significant action to transform care for pregnant women and their babies, including a new £127m investment to boost our workforce, strengthen leadership and improve culture – which is on top of an annual boost of £95m for recruitment and training announced last year.”
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