A devastated mother has shared a picture of her cradled stillborn baby as she criticised midwives who she claims ignored her concerns.
Stephanie Broadley, 28, broke down as she realised her baby boy, Beau, had been stillborn in May 2018.
She felt full of guilt that she had not pushed staff more strongly to listen to her concerns, including that she could not feel her baby moving while in labour.
Now a serious incident investigation had found that Mrs Broadley, from Immingham, was failed by staff at Grimsby’s Diana, Princess of Wales Hospital.
The investigation found her labour was not treated as high risk despite warning signs. Staff suffered ‘task blindness’ because they wrongly believed Mrs Broadley was low risk.
Mrs Broadley, who is a mother-of-six and married to Lee, 30, said: ‘I feel like I let him down. I feel that I should have shouted out for him more.’
Stephanie Broadley broke down as she realised her new baby boy Beau had been stillborn, shocked by the tragedy and full of guilt that she had not pushed staff more strongly to listen to her concerns
Mrs Broadley continued: ‘They just kept telling me everything would be fine and that it was normal, but I knew it wasn’t.
‘When Beau was stillborn it was absolutely heart-breaking. I just held him in my arms and sobbed, and it is so difficult thinking back now because I feel like I let him down.
‘I was repeatedly saying that I didn’t think things were right but now I wish I had been more forceful and loud. The problem is that you place your trust in the people who are there to care for you.’
Mrs Broadley had previously suffered a miscarriage prior to his conception and he was meant to be a ‘rainbow baby’, hence his name.
Determined to get answers, she contacted medical negligence specialists at Hudgell Solicitors and asked them to investigate the circumstances surrounding her son’s death.
This led to the Northern Lincolnshire and Goole NHS Foundation Trust admitting to a ‘breach of duty’ and errors in her maternity care.
The mother said that she had repeatedly asked staff about concerns she was having. But says midwives told her that everything was fine, even though the she believed that there were problems.
After Beau was born, Mrs Broadley says that she held him in her arms and sobbed, wishing she had been more forceful and loud with the staff about her concerns.
Mrs Broadley said: ‘I repeatedly said that I knew something was wrong and there were three occasions when I was in labour that I reported to midwifes that I couldn’t feel any movements at all, but no action was taken.
‘They didn’t increase heart-monitoring, even when I lost blood and it was a funny colour, and they didn’t call for a consultant to see me.
‘Midwives just kept telling me everything would be fine and that it was normal, but I knew it wasn’t.’
Investigations revealed that staff at the Grimsby hospital had wrongly assumed Ms Broadley to be a ‘low-risk’ case when she went into labour at 36 weeks pregnant in May 2018.
This was because her pregnancy records made reference to her having requested a midwife-led home birth earlier in her pregnancy.
However, as two of her previous five children had been born before reaching the full term – one of whom needed treatment for an infection – she was in fact a high risk pregnancy.
The investigation carried out at the Trust said the assumption of her being of low risk led to maternity staff suffering from ‘task blindness’.
It said the references to a planned home birth had altered the ‘perception of risk’ of staff and led to them failing to follow guidelines for treating mothers whose waters break before 37 weeks.
This meant she was not given antibiotics to prevent infection, and blood screening was not carried out as it should have been.
The investigation concluded that this led to ‘over optimistic’ records being written down, which failed to reflect the growing risk to baby Beau, and meant increased monitoring of his heartrate was not carried out as required.
The report said that key decisions were made ‘without actually assessing the patient and not having the full history’.
Criticisms were also made of a failure to escalate concerns to a consultant for high risk antenatal patient review, and was a two-and-a-half hour delay after a midwife had requested a registrar review.
Solicitor Sam Gardner, of Hudgell Solicitors, is negotiating damages with the NHS trust relating to Beau’s death and said that these cases are ‘never about compensation’ but ‘holding trusts to account for their actions.’
She said: ‘The hardest thing for any parents to understand and accept is that their baby has not come home with them from hospital because maternity staff have not cared for them as they should.
‘In cases such as this it is never about compensation, but holding Trusts to account for their actions and making sure such incidents are fully investigated.
‘Parents want answers, but sadly we all too often see the same conclusions, that avoidable errors were not prevented and basic guidelines were not followed.’
Mrs Broadley revealed that she was aware of a similar incident at the health trust seven months prior to the death of her son.
In this case, which happened at Scunthorpe General Hospital, staff failed to act appropriately to the mother’s raised blood pressure during labour, taking her risk from low to high.
This change of risk was not documented and only communicated verbally, leading to her not being medically reviewed and the baby’s heartbeat not being constantly monitored as it should have been.
Mrs Broadley believes that the health trust did not learn their lessons from this incident.
Mrs Broadley said: ‘That investigation was carried out at the Trust and completed just five months before I went into labour with Beau, but clearly nothing was learned across the Trust from it.
‘Given the ongoing reviews we have seen at other trusts due to failings to learn from mistakes, it makes me think there should be wider investigations into many other trusts. They can’t be allowed to keep failing families.
‘The sad thing is that we are seeing this continually happen all over the country and it has a devastating impact on families like ours for the rest of their lives.
‘My husband Lee still can’t face talking about losing Beau.’
Mrs Broadley has also been annoyed that Beau’s death did not qualify for further investigation as part of the independent Each Baby Counts programme, led by the Royal College of Obstetricians and Gynaecologists.
Beau was just four days short of 37 weeks, the eligible age to be investigated as part of the scheme, when he was stillborn.
She said: ‘We have the Each Baby Counts initiative but how can that be effective if it excludes a large proportion of baby deaths like Beau’s. That needs to be extended.
‘I am furious that significant changes to maternity are not being made. Midwives are undertrained and maternity units are understaffed.’
Mrs Broadley and her husband have been fortunate enough to have six healthy children, Logan, 10, Max, 8, Tyler, 7, Layla, 5, Teddy, 3 and eight-month-old Arlo.
They are also awaiting the arrival of another baby. But Mrs Broadley says that after the heartbreak of losing her son, she will only be happy once he arrives and is settled at home. She says the experience has led her to mistrust hospitals.
She said: ‘What happened with Beau has sadly left me mistrusting of hospitals. There are just too many cases, and too many scandals nationally and big changes need to be made.
‘We are fortunate in that we have six lovely children, and another on the way, but we had suffered a miscarriage before Beau and he was going to be a rainbow baby, that’s where his name came from.
‘Losing a baby because of the mistakes of health professionals is not something anybody should go through.’
Dr Peter Reading, chief executive at the Northern Lincolnshire and Goole NHS Foundation Trust, said: ‘I would like to offer my sincere condolences to Mrs Broadley and her family for their tragic loss.
‘We have carried out an investigation into the care Mrs Broadley received but unfortunately, as legal proceedings are still ongoing, we are unable to comment further on this case.’