By Anna Whittaker, Local Democracy Reporter
A bereaved mum whose baby was stillborn at a Nottingham University Hospitals Trust maternity unit told bosses face-to-face they must focus on listening to women in order to make improvements.
The woman said she was made to feel like she and her baby boy were “completely inconsequential” following six investigations by different organisations into what happened – a process which left her suffering from post-traumatic stress disorder (PTSD).
The woman, who asked not to be named, spoke during a ‘patient story’ section of a Nottingham University Hospitals Trust board meeting.
She told the trust board: “You need to be confident that we can have a culture in Nottingham where staff are supported, well trained, have gotten the basic needs met, and are able to speak up when things go wrong without fear of blame or negative repercussions.
“To achieve this, it’s essential that you achieve safe staffing levels.
“I’ve come here to ask you to always put at the forefront of your mind – what if this was affecting your daughter your mother or your sister?”
Her son was stillborn in 2017, which she says followed a community midwife dismissing her concerns about the baby’s lack of movement.
The midwife later stated in a report that the woman had refused to go to hospital.
The mum explained to trust board members how she was later “cross-examined” by a barrister in later hearing, who told her she should have been more concerned for her baby.
“I can accept the fact that my baby died and that humans made mistakes,” she said.
“But I honestly feel that the harm caused to us following my baby’s death was much, much worse to deal with than his actual death”, she told the board.
She acknowledged that “we’re all human and none of us are perfect” but said staff must prioritise “compassion, listening and learning” in order to improve.
Her story was heard by the board at a time when the organisation is already undergoing an investigation into maternity care failings led by independent midwife Donna Ockenden.
The maternity units at Queen’s Medical Centre and City Hospital have recently moved out of an ‘inadequate’ rating to ‘requires improvement’ by the healthcare watchdog the Care Quality Commission (CQC).
The trust says it has made improvements in maternity services including staffing levels, triage and the day assessment unit.
The CQC found in its latest report that women were being listened to – and all interactions between staff, women and their families were “caring,
positive and informative”.
As part of the board meeting, the mother told her story to bosses including Chief Executive Anthony May and Chair Nick Carver.
She asked the board to “sit with each individual experience, take it on board and try to do something positive with it”.
She added: “We need to acknowledge that healthcare experiences are often life-changing.
“That’s why we all work in healthcare, to do our absolute best to make those life-changing experiences positive ones, where even if bad things happen, the professionals looking after us are able to treat us with compassion and help us to feel safe again.”
The mum explained how she had previously experienced baby loss, so she was having extra scans for reassurance.
She said: “When I was nearly 27 weeks pregnant, I realised that I hadn’t felt my baby move for at least 24 hours and I became worried.
“I called my community midwife for advice and was offered an appointment that day.
“She listened to my baby’s heartbeat, told me that everything was fine, and sent me home.
“I now know that I should have been sent straight to hospital.”
She explained how a few days later, she still hadn’t felt her baby move and she was referred to the hospital.
She said: “I was on my own when I was scanned and told that my baby had died. I had to lie in that room for over an hour, whilst I waited for my husband to come in.
“All I wanted was not to be on my own. Not a single member of staff offered to sit with me. I had to give birth to my baby two days later.”
The mum said she thought she had just been “really unlucky”. Then she received a serious incident investigation report from the trust.
She explained: “In this report, the midwife had written a statement to say that I refused to have my blood pressure and my urine check and that I had refused to go to hospital.
“The report blamed me for my baby’s death by incorrectly stating that I had refused to follow the advice of my midwife.
“The damage that report did is still with me today, six years later.
“I then had to go through further processes over the next three years, which included six different investigations by different people and different organisations.
“I eventually gained a diagnosis of post-traumatic stress disorder. The PTSD was caused by repeated investigations.
“I’m now reliving it all again, as part of the ongoing independent review.”
The midwife was later part of a fitness to practice hearing by the Nursing and Midwifery Council.
The mum said that during this hearing, she was “cross-examined for two hours” by a criminal barrister who represented the midwife.
Her husband was not allowed in the room.
“I felt like I was on trial, and I had to attempt to defend myself, my child and my reputation, with no representation”, she said.
“I can still hear that barrister’s voice shouting at me across the hearing room, telling me that I should have been more concerned about my baby and that I was too busy with my other children.
“He said that I was vindictive, that I was untrustworthy and that I refused health care. He lied.”
The woman appealed to the board to “find a way to break through these barriers, which might feel impossible right now”.
She added: “Absolutely nothing is more deserving of your attention.
“I’m asking you to do this for me and my baby.”
Chair of the trust board Nick Carver replied: “I am so sorry that we failed you.
“It’s striking that it wasn’t the tragic death which caused your PTSD, but it was the way we behaved. I am so sorry for that.”
Dr Keith Girling, Medical Director, said: “It’s nice to see you again and thank you for telling us your story. It is incredibly powerful to hear the impact we had.
“I reiterate the apologies on behalf of the organisation and from any of the patient safety teams who were involved in the investigation processes.”
Anthony May, Chief Executive, added the story would “stay with us all for a long time”.
He said: “Since I’ve been in the trust, we are focused very much on culture.
“We are working with some of the families in the independent review and we absolutely want to harvest all of your experience so that the relationship with families is transparent.
“Your courage this morning has helped us get a little bit further down that journey.”
