A coroner has ruled that Addison Lea Stevenson could have survived had it not been for the “neglect” of hospital staff and “a gross failure in the provision of essential medical care”.
Image: Stoke Sentinel / BPM Media)
A midwife said a pregnant woman “faked it” when she expressed fears something was wrong with her baby just hours before the newborn girl died, an inquest has learned.
Little Addison Lea Stevenson was born prematurely after an emergency caesarean at 30 weeks and five days gestation, but died just hours later.
Heartbroken mother Donna Lea had been hospitalized three days earlier with ruptured diaphragms and taken to the delivery room as there was a high chance of a premature birth within 48 hours, reports said StokeonTrentLive.
An inquest found Donna should have stayed in the maternity ward as her care de-escalated, but she was transferred to the antenatal ward instead.
And midwives at Royal Stoke University Hospital did not respond to Donna’s repeated warnings that she had noticed a reduction in her baby’s movements, telling the hearing that one insisted the mother-of-four was “faking it”.
Stoke Sentinel / BPM media)
In a statement to the inquest, a maternity worker said she was “angry and upset” that her concerns were not addressed by the two midwives.
She said: “I emailed my station manager expressing concerns about an incident during this shift involving Donna.
“I was angry and upset that the two midwives had failed to respond to concerns. I have informed her on numerous occasions of concerns raised by Donna.”
The maternity worker then added that one of the midwives responded to her concerns at the time: “She’s faking it… she was just out for a cigarette, she can’t be in that much pain.”
However, this contradicted testimonies from both midwives, who said the maternity nurse did not inform them of the reduced movements of the fetus until 6.20pm, after which they responded to the concerns.
An EKG was performed which revealed baby Addison had tachycardia. Mum Donna was taken to the delivery room for an emergency caesarean, but Addison died just hours later, leaving her parents Donna and Nathan Stevenson heartbroken.
Addison died of complications from chorioamnionitis, and the physical found she could have survived without “neglect.”
North Staffordshire Assistant Coroner Sarah Murphy found that Addison’s death was “caused by neglect”.
She said: “There has been a gross failure to provide basic medical care. I find neglect. The death was caused by neglect.” She added, “It is very clear that the hospital foundation looked very closely at the system failures and the individual failures.”
Addressing Addison’s devastated parents, Miss Murphy added: “I hope you could see that the hospital took this death very seriously. Nobody can bring your baby back, but hopefully action will be taken if the same circumstances happen again. Now is the time to try to prevent a similar death. I hope this can bring you some consolation.”
A catalog of deficiencies delayed this diagnosis, including:
- Donna was not seen in person by a consultant obstetrician before her treatment was de-escalated and she was transferred to the antenatal unit on September 20. The examination concluded that she should have remained in the delivery room;
- When Donna was transferred from the maternity ward to the antenatal ward, her antibiotics for treating a urinary tract infection (UTI) and an intrauterine infection were reduced from intravenous antibiotics to oral ones after her results were “misinterpreted”;
- An opportunity was missed to conduct electronic fetal monitoring on September 20 in the prenatal ward. This would have led to a decision to extradite Addison earlier;
- There was a delay in diagnosing Addison as suffering from chorioamnionitis.
Donna Brayford, Quality and Risk Manager at Royal Stoke Maternity Centre, conducted a root cause analysis after Addison’s death. The Trust is now implementing an action plan of “systemic” changes.
Ms Brayford said: “The first major cause was the lack of personal attendance by the consultant on the ward round. We have now made it a mandatory standard for a consultant obstetrician to be present mornings and evenings in accordance with national guidelines.
“The second is that all mothers whose care is to be de-escalated should be seen by a consultant midwife. They remain in the delivery room until seen by a consultant obstetrician.”
Ms Brayford added: “We are also introducing a jump escalation process. When the support worker escalated her concerns to the midwives, she felt her concerns were not being addressed.
“She could now jump to the next person in charge to escalate her concerns. There are now posters all over the ward showing who to contact if you don’t agree with a decision.”
Also, a contributing factor to Addison’s death was a lack of staff in the antenatal ward. Ms Brayford told the Inquiry that 26 Band 5 midwives and five international midwives have since been recruited by the Trust and a further 20 are expected to be recruited by the end of the year.
Due to the disagreements between the midwives and the maternity nurse, a referral to the head nurse was also made to decide if further management investigations were needed.
The cause of death was given as 1A E.coli sepsis, 1B chorioamnionitis and in part 2 prolonged premature rupture of membranes.
https://www.mirror.co.uk/news/uk-news/midwife-said-pregnant-mum-faking-27267537 The midwife said the pregnant mother "faked" pain just hours before the newborn died.