"I still feel like our son could have been saved and the care I received before, during and after his birth was appalling."

A mother's experience of Oxford University Hospitals Maternity Services in 2019:

Firstly this hasn’t been an easy decision to share our story. As a nurse that works at the OUH I almost felt unable to do this. However, it’s been 6 years and I still feel like our son could have been saved and the care I received before, during and after his birth was appalling.

Our son was stillborn at 35+5 weeks in June 2019. I was 35 weeks pregnant when I noticed something wasn’t right, it was Monday afternoon and I felt a jolt of pain through my abdomen. I could hardly walk, I’d never felt anything like it before. I phoned MAU who wanted to see me. A CTG, cervical examination and a urine dip were carried out. I was told I was having contractions due to a UTI and was sent home with a course of oral antibiotics. I questioned how much pain I was in and they said give the antibiotics three days and if no better contact my GP.

The pain continued, it didn’t get any worse but it was still there, so after three days I contacted the GP who reviewed me and said they thought it was pelvic girdle pain and to organise a physio appointment. So I arranged a private physio appointment as an NHS one wasn’t available until after my due date. I never went to that appointment. I woke up the next day unable to feel the baby moving.

I contacted my community midwife who advised to call MAU. MAU made me feel like I was just being a paranoid first time mum. I had googled every way to get the baby to move... nothing worked. I was told to lay on my side for two hours, have some lunch and phone them back then.

In the meantime, my community midwife phoned to see how I was and I told them I still hadn’t felt the baby and had been told to wait two hours, she said ‘no, phone them back now!’. So I did and was told to come in, the person on the phone was clearly annoyed I hadn’t waited the two hours and taken someone else’s advice over theirs.

Below is some of the complaint I sent to the John Radcliffe a few weeks after our son’s birth.

In MAU we waited about 90 minutes before they popped the CTG on, they couldn’t find a heart beat so tried with a hand held Doppler and still no heart beat was found so they needed to get a doctor to carry out an ultrasound scan to confirm there was no heart beat. My husband and I were frantic, I can’t remember the exact time it took for the doctor to come however it felt too long. We were left on our own during this and also we were left on our own after being told our baby had died. As a nurse I felt this was wrong. I wouldn’t have left a patient after delivering such devastating news.

The doctor came to consent to start the induction process about ten minutes after telling us our baby had died, I can’t remember what I consented for or anything the doctor said and neither can my husband. It was almost too soon, as we were unable to process. Again I feel someone else should have been present for this to at least explain it to us afterwards. We then waited between 3 and 4 hours for a drug to be prescribed to enable us to go home, I feel this was an unnecessarily long wait. I appreciate doctors are busy but with EPR there was no need for such a long wait especially after we had been told our baby was dead.

We then went home after the drug was administered and were booked to return 48 hours later. However, I was admitted after 24hrs as I was in a lot of pain. There were several incidents that happened during my induction and after our baby’s birth that made an impossible situation even harder: 

• As my labour started the fire alarm went off and it appeared no member of staff knew the protocol, they changed their mind several times about needing to evacuate, this was incredibly distressing and felt incredibly disorganised. 10-15 minutes had gone by and discussions were still ongoing as to whether to evacuate.

• My relatives felt unable to give my husband and I enough time alone to process what we were going through due to the lack of a relatives room. They had several discussions with members of staff about this and they agreed they had a lack of appropriate places family could use. They were told they could use the cafes around the hospital which didn’t feel appropriate, they wanted somewhere in private they could go. 

• Whilst being moved to the delivery suite I noticed a set of notes on the end of my bed which had in large letters ‘STILlLBIRTH’ on it. I found this really upsetting and expressed my distress at the time and asked them to be moved out of mine and other peoples sight. This was all on show to every person in the corridor and the lift and I can’t put into words how I felt during that transfer. Later on, we found out these weren’t even my notes - they were from another patient and should have never been on my bed. How was this breach allowed to happen?

• After the delivery of my baby I was given a drug to suppress lactation. In the morning I was given a leaflet about the medication and told I would be given it shortly, the midwife was totally unaware I had already been given it and was about to give it to me again.

• I was told on many occasions I would need regular pain relief, I felt this should have been administered by the midwives without prompting, I wasn’t in a mindset to remember to buzz for pain relief every few hours. At no point during my admission did I have regular pain relief and at no point was I asked my pain score.

• We were told a bereavement midwife would spend some time with us, she spent a few minutes introducing herself and then came to consent for a post mortem and we didn't see her again, I was given the impression we would have a lot of time with her and it felt very brief and not very helpful.

• The midwife made a drug error during my induction, she gave a double dose of the induction pessary twice. I was told about this as soon as it was discovered. She reassured me this wouldn’t affect my induction and it was safe to give another dose. However once my labour started it was incredibly intense and I can’t help but wonder whether this was because of the drug error.

• During labour I was told I wouldn’t need to be fully dilated as the baby would be small, the midwife instructed me when to push. My baby was 6.8lb! I tore really badly needing a lot of stitches which I feel could have been avoided if I had waited until I was fully dilated.

• After the birth I needed stitching and I felt every single stitch! It was almost worse than the birth. I was screaming and not once was I offered any pain relief or extra local anesthetic. I was told the doctor had to get back to an emergency before she even started, so she was obviously in a rush and didn’t have time to worry about the pain I was in!

They took over the 25 days they should have done to respond to our complaint and what followed was lots of back and forth with no answers and just apologies and excuses. At this point our son hadn’t had his post mortem. We now know he died of a concealed placental abruption. In our eyes he could have been saved. I saw three healthcare professionals in the week leading up to our son’s death and they all diagnosed me with conditions I never had.

We can’t prove that an ultrasound would have picked up the abruption but I had misdiagnosed pain, it was later confirmed that I didn’t have a urine infection (only finding this out for myself after requesting the medical notes) or pelvic girdle pain. I was given a 7 day course of antibiotics I didn’t need. It isn’t policy to contact patients with normal results, but how is it right to not inform someone. I would have stopped taking those antibiotics and contacted MAU to say I’m still in pain and it’s not what I was diagnosed with! Maybe then they would called me back into MAU for further assessments due to my ongoing pain.

The access in and out of the maternity unit is also awful. I cannot find the words to express how I was feeling as I was discharged - having to share the only lift in the building with new parents who were experiencing the best day of their lives as they proudly carried them out in their car seats, whilst I held my memory box.

I could write a whole separate story about our subsequent pregnancy during Covid and not being able to have the moments I longed for with my Son - but for now, this is the story I’m ready to share.