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Thursday, 8 November 2012

Worse than we could've imagined....

Last week we received the official investigation back from the hospital, into what happened during my pregnancy and labour with Harry that ultimately cost him his life.

I had accepted the fact that Harry had died because I had the condition, vasa previa, and during labour my contracting uterus around his head had caused a major vessel to rupture as my placenta had grown his umbilical cord in an usual place and this was growing over the exit to my uterus. I had seen the blood but had always thought that blood was mine, and until Harry was born it appears that all the health care professionals had too.

After reading my notes and writing complaint letters, and meeting the senior midwife in the hospital, it started to become clear that there were a few points where things should and could have been done differently.
One of these points was this idiot doctor that I had. When he tried to break my waters, it was ridiculously painful and when he decided I needed an epidural he snapped off his gloves and walked out. Both him and the midwife examining me could feel something in front of Harry's head. We all know what this was, now... but why did he not pick this up when he scanned me in the labour ward? This is something that will plague me forever, but I understand this doctor is no longer employed at the hospital so that makes me feel a little more secure.
The other point was that I was left to bleed for four hours. I had a catheter fitted after my waters broke at 5.30pm and I was not checked again until 9.30pm when we discovered the bleed. Apparently, a labouring woman's "loss" should be checked every 30 mins, especially if she has an epidural fitted. That is a fair few checks missed. And it's not because she was rushed off her feet. We were her only patients.

When I received the investigation via email, I was feeling nauseous. What if the investigation said that nothing could have been done differently. What if there were huge findings that were ultimately the cause of Harry's death. How will I feel? What will I do? These thoughts rushing through my mind.

I open it. I scan read it for the "information". I find what I am looking for.... wow. So many more things that I was not aware of.

I have cut and paste this from the document I received:
Care and service delivery problems
  • Emergency bell not used to call for assistance in the room following vaginal (PV) bleed.
  • Midwife left the labour room following a significant PV bleed.
  • No ‘in room’ matron review or matron ‘fresh eyes’ on CTG.
  • No CTG sticker used by Registrar during review at 22.00.
  • Fetal scalp electrode (FSE) applied but abdominal transducer not unplugged resulting in fetal heart (FH) trace recording at 20bpm above the actual rate.
  •  The time, from decision to request a review by Specialist Registrar (SpR) following the PV bleed and VE, and his presence in LW room for the review, was 20 minutes.
  • ‘Category 1 caesarean section’ 2222 call not put out when changed in theatre from category 2. 
  •  Placenta not examined until HC transferred to NNU and NC out of theatre.


Contributory factors
Ruptured vessel from vasa praevia.

The decision to go to theatre was initially graded as category 2 and as such all appropriate people had been contacted to attend theatre, including a Paediatric F2 (junior doctor). Due to deterioration of the FH, as observed on the CTG, the operation was upgraded to a category 1 caesarean but the guidance, to call 2222 for a category 1 caesarean section, was not followed. Had this been done the neonatal registrar and a neonatal Matron would have responded and attended theatre as soon as they were able to. (The doctor arrived when Harry was approx 25 mins old)

It was thought that the earlier blood loss was maternal; most likely being due to a placental abruption yet, at surgery, there was no evidence to support this view. It may have helped the neonatologists in their treatment of HC to know that there was no evidence of an abruption, generally indicated by some shearing of the placenta from the uterus and a retro-placental clot. However, the Neonatal Registrar does not consider that this information, if provided within the first 25 minutes of HC’s life, would have made a significant difference to the resuscitation efforts being made without that information. (As he had already lost such a lot of blood already)

Although, as is usual practice following caesarean section, blood was taken from the cord for blood gas analysis (pH), the placenta was not examined until both NC and HC were out of theatre. While it is not unusual, in the absence of maternal bleeding, to postpone this examination for a short time, in this case the early recognition of vasa praevia, with a visibly torn vessel, may have influenced the treatment choices for the neonatologists. The Neonatal Registrar agreed that, had she been made explicitly aware of the vasa praevia and torn vessel, she may have considered giving blood earlier but is unsure that, if blood were administered sooner, this would have changed the outcome for HC, given the significant loss of blood that he had already experienced.

 * * *
So, along with the fact that I felt the Gynae doctor who scanned me in labour should've picked up the vasa previa/velamentous cord insertion, the midwife should've checked me more frequently, the CTG traces (in hindsight) show decelerations from the time my waters broke, and now the change of category for my c-section delivery and the non-diagnosis of the cause of the bleed until later... along with the clip they used on Harry's head to monitor his heart rate causing issues with the reading on the CTG monitor, to be incorrect by 20bpm as they didn't remove the monitor from around my bump.... 

Good Lord. How on earth am I ever going to be able to trust someone to deliver a baby again? So many errors. So many people not doing their jobs correctly. How did I feel? I felt numb. I didn't feel angry like I thought I would. I wasn't sad. I think I was shocked. But mainly I felt the feeling of being robbed all over again. If only, if only... I wish I could stop all these "if only"s... things can and won't ever change for my Harry. What has happened, has happened, and nothing can change the result for my little boy. But what can change, is to ensure this NEVER happens again to another family, waiting to meet their little boy.

At first I felt like meeting with the hospital would be a waste of time, what could I get out of it? I know what happened now... But after a few days of considering it, I have decided to go for the meeting. I want to know EXACTLY what is happening to ensure this never happens again. 

My meeting is next Tuesday. I will keep you all posted.

2 comments:

  1. Even as someone who suffered medical negligence during my own birth I am still dumbfounded by the catalogue of critical errors during Harry's. I do hope that you achieve what you want to achieve and get what you want from the meeting. I always regret not taking my hospital to task for what was basically one midwife's negligent treatment of me, but then I feel a bit ashamed as at least I brought my baby home eventually. What makes this all the more heartbreaking is that you don't even seem to want revenge, you simply want to make sure that no one else suffers as you have. I find that incredible and so admirable xX

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