A 28-year-old Birmingham mother has said the care she received at Midland Metropolitan University Hospital in Smethwick was 'substandard' and 'could very easily have cost my son his life' after her newborn baby needed 12 minutes of resuscitation at birth. The boy, born on October 22 last year, was handed to his mother by a midwife despite being clearly not breathing, she said.
The mother, who wishes to remain anonymous, said she 'screamed' when the midwife gave her the baby. It took 12 minutes for the infant to be resuscitated, and the family later learned from an investigation that the resuscitation machine had been switched off and was not working for the first seven minutes after birth.
Baby suffered oxygen deprivation and transferred to specialist unit
The newborn survived after receiving 12 minutes of resuscitation and breathing support, but suffered hypoxic ischaemic encephalopathy (HIE), meaning his brain did not receive enough oxygen and/or blood flow around the time of birth. He was transferred to another hospital for therapeutic cooling – a process used to lower body temperature and prevent brain damage in infants – in a dedicated neonatal unit.
Medics carried out an MRI scan three days later, which showed a normally formed brain with no evidence of structural abnormality. His parents were able to take him home on October 30, but doctors warned them his development would need close monitoring due to concerns over suspected hypertonia, a condition marked by an abnormal increase in muscle tone and stiffness, making muscles tight and resistant to stretching.
Parents face 'constant worry' over development
The youngster, now 10 months old, was making good progress after repeated physiotherapy, but his mother said it had been a 'constant worry'. She said: “We were told that despite his MRI coming back as showing no brain injury, there was a concern over possible mild Cerebral Palsy, and that we’d need to keep a close eye on his development as he had suspected hypotonia.
“When he started crawling, he would only use one leg and he was really struggling. We took him to regular physiotherapy sessions, and I was constantly researching the best ways to help him, such as warm baths to help his muscles. It has been a constant worry though. Thankfully at his last assessment, specialists were happy with his progress, but its still a case of seeing how he progresses and if there is any longer-term impact.”
MNSI review finds multiple failures in care
A Maternity and Newborn Safety Investigations (MNSI) review later identified a number of areas of concern over the care provided during labour and delivery, plus failures to adhere to local guidance. The review found an emergency call was made 39 seconds after the boy's birth, with breathing support provided to resuscitate him. A team of neonatal doctors and nurses arrived in the room four minutes after birth, but more than seven minutes had passed from birth before it was noticed that the resuscitaire machine was switched off, which 'possibly explained why his condition deteriorated after initial resuscitation'.
The review also highlighted how there was no documentation of a CTG review – which evaluates a baby's heartbeat and the mother's contractions – being conducted for 82 minutes before he was born, leaving a gap in assessment. Guidance states CTGs should be taken, reviewed and categorised at least every 30 minutes during the second stage of labour. The review also found the delivery team had failed to identify that the baby boy had a 'pathological CTG' – suggesting significant warning signs of stress or lack of oxygen – which 'impacted decision making when planning for birth.'
The mother's placenta was also disposed of before being stored and sent for histological examination, a process which can help identify complications and determine the cause of any issues with a baby's health.
Mother describes traumatic birth experience
The boy's mother added: “The care I received during labour and birth was substandard from start to finish and could very easily have cost my son his life. I was induced at 40 weeks as I’d had a really difficult time emotionally during the latter stages of pregnancy, losing both my mother and my mother-in-law, so the fact that I was induced should have triggered closer monitoring.
“It was clear that during labour there were issues. The midwife kept saying that my baby’s heart rate was similar to mine, and we kept asking what that meant. I asked on a number of occasions if I needed a caesarean section to ensure my baby’s safety, but that was ignored. I was made to feel like I was panicking over nothing.
“When he was born the midwife handed him to me and I screamed out because it was clear that he wasn’t breathing. I still cannot understand why she would have done that. It took 12 minutes to resuscitate him, and we have since found out from the investigation that the resuscitation machine had been switched off and wasn’t working for the first seven minutes after he was born.
“After he’d been in the neonatal unit and had the MRI scan which said he had no brain injury we were obviously massively relieved, but we were then told that he could still have mild Cerebral Palsy, and that his development may still be affected. Since the moment my son was born, we have been extremely concerned about his health and development, and we will continue to do so throughout his early years. He is thankfully doing very well at present, but we worry all the time about the impact it had on him.”
Legal action and hospital response
The parents have instructed medical negligence specialists Hudgell Solicitors to represent them as they seek answers over the treatment provided. Solicitor Maria Repanos said: “The MNSI report identified that there were failures in respect of adequately documenting and monitoring the baby’s heartrate on the CTG trace. Upon the basis that the pathological CTG was not recognised, expedited delivery did not take place. Failure to identify this affected decision-making regarding birth planning. This strongly suggests there was a missed opportunity to intervene particularly given that the baby was born requiring resuscitation. Hopefully lessons have been learned as a result of this.”
Claire Macdiarmid, director of midwifery at Sandwell and West Birmingham NHS Trust, said: "We are deeply sorry for the distress this experience has caused. An independent investigation carried out by the MNSI programme identified a number of areas where care fell below the standards we expect, and we have already acted on the findings to strengthen our maternity and neonatal services."
