BY RAFI BENADY
A mum whose baby died at 10 days old has expressed her fury after the coroner publicly ‘doubted the veracity’ of the two midwives involved in the botched birth.
Bethan Harris was born on November 16, 2018 at St George’s Hospital in Tooting, and died at the Shooting Star Hospice in Hampton, 10 days later on November 26, as a result of brain damage as she was being born.
Coroner Dr Sean Cummings at West London Coroner’s Court concluded she “sustained severe brain injury during delivery” in his narrative verdict.
Dr Cummings said in his written summing up published on November 19: “I did not find MW [Ann-Marie] Dunbar or MW [Jemma] Prasad to be convincing and even more regrettably I doubted their veracity.”
His report said there had been a “failure to provide basic medical care” in some respects. And he added if different action had been taken it might have resulted in Bethan being born in “better condition”.
But Dr Cummings added in his report he was “unable to provide a clear and direct link” between medical failings and Bethan’s death, and there wasn’t enough evidence for a case of neglect.
Baby Bethan’s parents, Fran Heatley, 37, and Doug Harris, 37, both from Streatham, were elated in February 2018 to find out they were having a daughter.
There were no medical problems during the pregnancy. Fran went into labour on November 16, 2018.
She was planning to give birth in the midwife-led Carmen Suit Birthing Centre at St George’s, but it was full, so she was taken to the labour ward.
Dr Cummings’ summary added:
- Beth’s heartbeat soon dropped to dangerous levels,
- Fran entered the triage unit at 3.45am
- At 5.05am MW Prasad tried to establish the child’s heart rate in what Dr Cummings describes in his report as “the tipping point”.
Fran said this week that she was told more than once by MW Prasad she couldn’t find the heartbeat, including after she was moved on to her side.
Dr Cumming’s summary also added:
- Fetal medicine specialist Dr Lasaking told inquest the midwife should have pressed the emergency button within three minutes
- Dr Lasaking said this issue had caused the “bulk of the injury to Bethan’s brain”.
- Obstetric resident senior registrar Dr Vardy told the coroner the midwives were having problems for 20 to 30 minutes.
Fran added this week: “Most of the damage clearly happened in labour, particularly in the last few minutes.”
MW Dunbar suggested to MW Prasad CTG monitoring should be undertaken, the summary adds. Dr Cummings’ report added how the midwives eventually called Dr Vardy, who said the baby must be delivered urgently.
The team then ruptured Fran’s waters, which led her to push Beth out with ease. But Fran said this week: “She was there just pale and floppy. In my heart of hearts I feel if there had been better oversight from the start, things could’ve been different.
“We have to live with the fact they could’ve done more to save her.
“They told us they’d give us a written apology. I’ve never received it.
“I would never go back to St George’s for future pregnancies.
“They were in and out, no-one was really with us.”
The couple were shocked to find when they received a copy of the medical notes that meconium – or stools of the fetus – had been noticed in the fetal sac, suggesting Beth was distressed, and her heart-rate should be monitored.
Dr Cummings’ report states MW Prasad said she had not seen the meconium as the lights had been dimmed.
Fran said last week: “One of the midwives said she told the other one to start the heart-rate monitor; the other said she never heard the order.”
But Dr Cummings said: “I find it was incumbent on MW Dunbar as the more senior midwife present – she was the Triage Midwife – to insist on the placing of the CTG.
“In my view it is likely MW Prasad did know [that there was meconium present] and did not act at the time, for reasons unknown.
“Had the membranes been ruptured it is more likely than not that delivery would have been expedited and the situation with the plunging fetal heart rate obviated.
“I consider it more likely than not that Bethan would then have been born in better condition.”
But he was unable to conclude that the mistakes were the probable cause of Bethan’s death.
He said in his findings: “Unfortunately I cannot say on the balance of probabilities even with this intervention that Bethan would more likely have survived longer term.”
Fran said after the inquest: “At the inquest MW Dunbar seemed to me to be obstructive, and I think this is one of the reasons why he should refer MW Dunbar and MW Prasad to the NMC (Nursing and Midwifery Council).
“With the inquest, it’s not about attributing blame, it’s about finding out how she died.
“There were lots of little mistakes. I’ve had an internal and an external investigation.
“You can’t really say that ‘this’ caused the death, and the coroner couldn’t, but we know they didn’t do everything they could’ve.”
She accused the hospital of being off-hand with her: “I’ve been corresponding with the hospital for the past year. They were quite dismissive when I tried to find out how the midwives had been retrained.”
She said all she wants from the inquest is to know this will never happen again. She thinks it’s essential the midwives be given extra training by the NMC.
The coroner’s report describes how Beth was then placed in a cool incubator in the neonatal unit for three days to limit brain damage. But she didn’t recover.
Ms Heatley and Mr Harris chose to move her to children’s hospice Shooting Stars, where she passed away seven days later.
Fran thinks the problem lies with the hospital’s procedures. She said this week: “It was reported as an adverse incident and not upgraded to a serious incident for four months.”
Fran said the ordeal has brought her and Beth’s father, Doug, closer together.
She attributes her being able to cope to her family and friends, and the counselling the couple had at Shooting Stars.
The couple have been raising funds ever since for the hospice, which supports 700 children and their families in Surrey and 15 London boroughs.
A spokesman for St George’s Hospital said: “We are sorry the care Ms Heatley received fell short of the high standards we expect, and we would like to apologise sincerely and unreservedly to Ms Heatley and her family for this.
“We will continue to look at new and additional ways of improving the service we provide to all expectant women under our care.”
To contribute to Shooting Stars go to: https://www.justgiving.com/fundraising/bethsgift19
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