The death of a tiny baby after mum suffered from pre-eclampsia could have been avoided, bosses at Kettering General Hospital have admitted.
Kimberley Wilson from Wellingborough was displaying signs of pre-eclampsia in June 2016, a month before her due date, but chances to escalate her care were missed.
Her baby Ava Wilson-York subsequently died and KGH NHS Trust have paid an undisclosed settlement after admitting liability.
A serious investigation report published by the Trust found that Ava’s death was ‘avoidable’.
Kimberley, 27, a care assistant, and her partner Paul York, 30, found out they were expecting their first child in late 2015. Kimberley was placed under the care of Kettering General Hospital and given a due date of July 13, 2016.
Following a visit to her GP on June 14, 2016, with swollen legs and ankles, Kimberley was referred to Kettering General Hospital’s maternity unit to check for pre-eclampsia.
After several hours she was discharged home to attend twice weekly community midwife appointments.
On June 17 Kimberley was reviewed by a midwife and her legs and ankles remained swollen. Protein was found in her urine. She was booked in for another appointment three days later. Kimberley was advised of the symptoms of pre-eclampsia and told to call the hospital if these occurred.
On June 19 Kimberley telephoned Kettering General Hospital complaining of abdominal pain, but was advised to stay at home and take a bath and painkillers.
She was reassured that her symptoms were normal and there was no need to attend hospital.
Kimberley called Kettering General Hospital again. She was advised that she could attend hospital, but if she did she would have to wait if she wanted to be seen as the delivery suit was very busy.
Following this she called another hospital and attended its maternity ward. Following tests Kimberley’s blood pressure was high and she had increased levels of protein in her urine. She started undergoing treatment for pre-eclampsia. However, by this time it was too late and doctors could not save Ava who was delivered by caesarean section.
The Trust admitted in their response letter that the symptoms displayed on June 17 were indicative of pre-eclampsia and warranted referral to hospital and admission.
Had she been appropriately admitted following onset of pain, she would have had CTG monitoring and baby Ava would have been delivered by caesarean section. Ultimately baby Ava’s death would have been avoided.
It was also noted in the Trust serious untoward investigation report that the telephone conversation Kimberley had with the hospital on June 19 prevented her from having timely and local care.
Kimberley said: “I was becoming concerned that something wasn’t right. I was being sick and the pain was getting worse.
“It got to the point where we had to try another hospital. From that point everything just moved so quickly. I will never forget when the staff told me that my baby didn’t have a heartbeat.
“To make it worse after Ava was delivered I could only hold her for a short while. She was perfectly formed and weighed 5lb 1oz but the doctors had to take away because I was so poorly.
“Time may have moved on from Ava’s death but life hasn’t. I say that I am fine and coping but I’m not sure I will ever get over losing Ava. I sit there at night going over everything that happened and why it did.
“Both me and Paul feel completely devastated by the loss of Ava.”
Kimberley and Paul have now joined her legal team in using Baby Loss Awareness Week to call on Kettering General Hospital NHS Foundation Trust to learn lessons from the incident.
Rosalie Reading, specialist medical negligence lawyer at Irwin Mitchell representing Kimberley, said: “Pre-eclampsia is a severe type of high blood pressure in pregnancy that can have tragic consequences for babies and can leave mums seriously ill.
“Understandably Ava’s death has had a profound effect on Kimberley and Paul who feel badly let down by the events that led to Ava’s avoidable death.
“While nothing can ever make up for their loss we are pleased that the Trust has accepted liability, allowing the couple to try and rebuild their lives the best they can.
“Baby Loss Awareness Week is an important time for reflection but also to promote the help available to families who have suffered the heartbreak of losing a child regardless of the circumstances.
“We now call on the Trust to ensure it learns lessons from Ava’s death so other families do not have to suffer the heart-break that Kimberley and Paul have.”
Director of Nursing and Quality for Kettering General Hospital, Leanne Hackshall, said: “We are deeply sorry for the loss of baby Ava and for the life changing consequences that this has had on her parents.
“Immediately after this sad event we launched an external serious incident investigation to establish the circumstances that led to the death of Ava and identify what we could have done differently.
“I would like to reassure Ava’s parents and our patients more widely that we have learned from Ava’s death.
“This has included establishing improved systems to ensure that all contact with the maternity service is logged onto the electronic patient record system and readily available to all of our staff so that we always have a complete overview of previous discussions and case history.
“We have also improved our guidelines around how we monitor women with raised blood pressure and shared learning with all staff through our skill drill sessions. Alongside these developments we have also held specific learning sessions for all staff across the maternity service around communication skills”.