Kettering hospital maternity investigation into death of two-day-old baby finds guidance was not followed

Baby Ralphie Leach-King-Rhodes died in his mum’s arms at 35 hours old, prompting the Maternity and Newborn Safety Investigations (MNSI) report looking into the circumstances of his care.

Ralphie was delivered by emergency caesarean at Kettering General Hospital in March 2025 – he was born without a heartbeat and had to be resuscitated.

His parents Ruby Leach, 22, and her partner, Jacob King-Rhodes, 23, from Market Harborough, who also have a four-year-old daughter, Roma, welcomed a baby girl, Rosabella, in March this year.

Ruby said: “When I found out I was pregnant, I was so happy. When we showed Roma the ultrasound photos and told her she was going to be a big sister, she was so excited. It was a perfect moment.

“We were all looking forward to meeting Ralphie. We wondered what he would be like, what he’d enjoy and what he’d grow up to be. We expected to spend our whole lives with him, but we had less than two days.

“We’ll never forget those precious moments we were able to spend with him, showing him just how loved he was.

“I carried him for nine months and he passed away in my arms. That broke me.

“The pain I felt in that moment is the kind of pain only parents who have lost a child can understand. It’s something that will stay with me forever. I’ll always be Ralphie’s mum and that will never change.”

The couple took Ralphie to Rainbows Hospice for Children and Young People so Roma could meet him and say goodbye to her baby brother.

Thanking the staff, Ruby said: “We would like to thank the staff there for everything they did for us. They were the most amazing people, so kind and compassionate, and we will always be grateful for the support they gave our family.”

The independent investigation report by the MNSI programme identified a number of concerns regarding the care provided to Ruby under Kettering General Hospital NHS Foundation Trust in the days leading up to Ralphie's birth.

Reports do not attribute blame or responsibility but share findings that identify factors that have led to harm or may lead to harm in the future.

As well as the findings reports may include safety recommendations and safety prompts to improve healthcare systems and processes.

What happened in the care of Ruby and Ralphie?

In the weeks before his birth, Ruby had attended hospital several times, including twice with concerns about reduced movements of her baby.

Ruby, who was aged just 20 at the time, had a raised blood pressure reading but wasn’t diagnosed with the condition by staff, the independent investigation found.

The report also found hospital guidance wasn’t followed, Ruby’s maternity warning score was incorrectly calculated and she didn’t receive a senior doctor review within the required 15 minutes.

At 38 weeks and three days pregnant, Ruby attended maternity triage at Kettering General Hospital for the second time with concerns about reduced baby movements and pain around the scar from a previous caesarean section.

After an initial assessment, she was placed in the trust’s orange priority category, meaning she should have been reviewed by a senior doctor within 15 minutes. However, the investigation found she was instead reviewed by a junior doctor more than an hour and 40 minutes later, before being discharged home. The report concluded that trust triage guidance was not followed.

The investigation also found that Ruby’s maternity early warning score was recorded incorrectly. Investigators concluded this meant her care was not escalated and she was not reviewed by a senior doctor in line with trust guidance.

At a routine appointment the following day, investigators found staff did not recognise that Ruby’s blood pressure was raised under trust guidance. As a result, it was not rechecked and no further monitoring was arranged before she went into labour.

Five days later on March 30, 2025, Ruby attended hospital after going into labour at 39 weeks and two days pregnant. Staff found Ralphie’s heart rate was abnormally low and emergency assistance was called.

Ralphie was delivered by emergency caesarean section and admitted to intensive care following resuscitation.

Tests showed that Ralphie had developed severe hypoxic ischaemic encephalopathy, a type of brain injury caused by a lack of oxygen to the brain around the time of birth. He also developed multi-organ failure.

Ruby has now instructed specialist medical negligence lawyers at Irwin Mitchell to investigate whether more could have been done to prevent Ralphie’s death.

What the hospital said

UHN Director of Midwifery Sarah Jamieson said: “We extend our sincere condolences to Ralphie’s family on their loss and recognise the devastating impact it will have had.

“We fully co-operated with the Maternity and Newborn Safety Investigations programme who always carry out an independent review in cases like this in order to make safety recommendations to improve services at local level and in some cases across the whole maternity and newborn healthcare system in England.

“We remain committed to learning from every incident of baby loss to support the safest possible care in the future and are acting on the MNSI recommendations.”

Ruby added: “I’m so grateful for my family. Roma and Rosabella mean the world to me and are the reason I keep going on the days when I don’t feel like getting out of bed. Jacob has also been my rock through everything. It’s been heartbreaking for him too and we’re doing our best to be there for each other.

“Moving forward with our lives has seemed impossible for a very long time, but we hope that getting answers might bring us some form of closure.

“We may never know exactly why Ralphie died, but we want to understand whether more could have been done and if opportunities to help him were missed.

“Nothing can make up for the time we lost with Ralphie, but I’m determined to make sure his death wasn’t in vain. We hope by speaking out we can help save lives and spare families from the heartbreak we’ve experienced.”

Looking for further answers

Irwin Mitchell lawyer Lauren Mannion said: “When a family experiences the loss of a baby, they’re often left with many questions and facing a complex system to get answers. Understandably, Ruby and her family have a number of concerns about their maternity care leading up to Ralphie’s birth and we’re now investigating further to help provide them with the clarity and answers they deserve.

“Nothing can change what happened, but it’s important that all of the issues raised by the investigation are fully examined and that any lessons that could improve maternity care are learned.”