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Enquiry into Bo's death

(75 Posts)
bubble99 Fri 29-Apr-05 23:32:34

We met today with the cosultant obs. who is in charge of reviewing our case and, by coincidence, was our 'named' consultant and The Head of Maternity Services. The meeting lasted for two and a half hours and it was horrible to have to re-live the whole experience again in detail.

The post mortem results showed that there was nothing wrong at all with Bo. He was a healthy 7lb7oz baby boy who had grown well.

The MW at our booking appt. had written at the end of her entry "Needs consultant appointment" addressed seemingly to no one in particular, she obviously couldn't be arsed to make it herself and despite my GP writing and requesting an appointment it eventually fell to me to make the appointment. Fine for a reasonably intelligent, medically aware person like me, but not so fine if I'd happened to be someone who couldn't speak English and/or didn't realise the need to see a consultant.

We'd been booked into the diary by the MW at the antenatal clinic for induction on the evening of the 16th February but this had not been passed on to the maternity unit. We phoned as requested at 5pm on the 16th to check that there was a bed available. We did and were told that there were no beds on the antenatal ward but to come in at 8.30pm anyway. When we arrived we were put in a room on the postnatal unit. Those investigating had been told by the staff that they had 3 beds available on the AN ward but that they'd put me in a single room elsewhere because I had shoulder pain and they thought I'd be more comfortable there. Absolute crap as I hadn't mentioned my shoulder pain when I'd phoned earlier and they only knew about it when I arrived at the hospital.

The entire unit was so short staffed that evening that they'd had to close the active birth ward and four antenatal beds. This information was not volunteered and only given today when I asked a direct question.

Up until two years ago the maternity unit had a 'bleep holder', a senior midwife who's role was to coordinate and be aware of potentially difficult inductions such as mine. This post was dropped as the bleep holder was supernumerary and could not be incorporated into staffing numbers. The bleep is now held by a midwife who is probably up to her eyes trying to run her own (short-staffed) area.

There was a total breakdown in communication, we should have been moved to the labour ward for immediate induction within an hour of admission, not seven hours later. The labour ward was full as there were insufficient staff to move those mothers and babies ready to go to the post natal ward.

My notes were full of references to my shoulder pain (which was acknowledged to be muscular and not a life threatening pulmonary embolism within two hours). No plan of action made for delivery of the increasingly distressed twins.

The CTG traces had been picking up the same twin for two and a half hours and this had not been recognised. The attempt at vaginal delivery was apparently the right course of action as they wanted to attach fetal scalp monitoring and see if there was meconium in the amniotic fluid. Mr Bubble pointed out that at this point twin 2 was really struggling and they could not break his waters anyway. They maintain that the babies' tachycardias(fast pulse rates) were not cause for concern in themselves as they were respondant to my pulse rate which was at that time fast. No kidding.

A consultant anaesthetist arrived at this point during the meeting and told me that the attempts at spinal anaesthesia had been abandoned on the direction of the obstetrician who performed my CS. To this I replied, and it was the only time I swore, that if so they must have been f***g telepathic because at that point there was total silence in theatre and that it was me who'd insisted on the general anaesthetic. He decided then that maybe after I'd said it the obs. nodded her head to agree. WTF

Not one MW or doctor thought to check that the consultant had been informed of the deteriorating clinical situation.

I was flat on my back for 30 minutes while they tried and failed to intubate me. This caused hypoxia in me as my lungs couldn't fully inflate. The blood supply to the placenta was also severely restricted. The respiratory depressing anaesthetic agents had been crossing the placenta for too long before a succesful intubation was achieved and it was the combination of these things that killed Bo.

We now await the full report in writing and will discuss the proposed actions/policy changes in detail at our next meeting.

BTW. We were told that the whole case was also being reviewed by 'The Clinical Governance Facilitator'(sp) WTF. How much is he/she on? No money to pay MW's a liveable on salary but enough for yet another 9-5 bod to mop up the piles of poo that understaffing causes

bossykate Fri 29-Apr-05 23:35:53

so, so i'm so sorry.

sallystrawberry Fri 29-Apr-05 23:39:03

Message withdrawn at poster's request.

pixiefish Fri 29-Apr-05 23:39:08

oh bubble

Jayzmummy Fri 29-Apr-05 23:39:40

soapbox Fri 29-Apr-05 23:39:41

Bubble - you and Mr Bubble must be wrung out this evening

It all sounds so normal in its ineptitude that one might be forgiven for forgetting that a child lost their life that night in entirely avoidable circumstances

I'm so sorry for you all, I hope this gets easier to bear with time, but I can't imagine how it will

MarsLady Fri 29-Apr-05 23:39:52

Yorkiegirl Fri 29-Apr-05 23:40:17

Message withdrawn

lilsmum Fri 29-Apr-05 23:40:35

dont know what to put except... and very on your behalf


Evesmama Fri 29-Apr-05 23:40:49

im so sad for you hun
i dont want to 'vent' as i dont want to upset you, but you know what ill be thinking
you will never get 'justice', but hopefully those incompetant arseholes will be held resposable for their actions..or lack of them

great big bear hug for you

Newbarnsleygirl Fri 29-Apr-05 23:41:03

AngelCakeUmm Fri 29-Apr-05 23:41:04

Bubble i am really really sorry you are having to go through such a bad bad time {{{hugs}}}

lilsmum Fri 29-Apr-05 23:42:13

well these "apparent professionals" have to live with themselves, and what they have done

sobernow Fri 29-Apr-05 23:44:05

Message withdrawn at poster's request.

jamiesam Fri 29-Apr-05 23:46:01

Oh, I'm so sorry.

Aero Fri 29-Apr-05 23:48:39

no words........just - so sorry for all this.....

unicorn Fri 29-Apr-05 23:54:51

I'm so, so sorry.
You have every right to be angry.

I'm sure if I were in your position I would sue, not for the money(of course no money can bring back Bo) - but to make sure this whole farce of understaffing in the the NHS is highlighted, and ensure that changes are made urgently.

No more babies lives should be lost.

Big hugs to you and Mr Bubs... you have my total admiration and respect.

sunchowder Fri 29-Apr-05 23:59:49

Bubble, so sad to read this. You are in my thoughts.

flamesparrow Sat 30-Apr-05 00:04:36

As many have said before me - no words can say anything,

suzywong Sat 30-Apr-05 00:13:46


Satine Sat 30-Apr-05 00:20:04

What an awful awful time you must be having. You're all in my thoughts.

ggglimpopo Sat 30-Apr-05 00:20:56

Message withdrawn

mears Sat 30-Apr-05 00:31:55

Oh Bubble - how wrung out you must feel after today. What is the next step? Apart from waiting for the report, are you able to go to Independanet Review? I don't think you have had satisfactory response. How can they admit traces were the same for 2 1/2 hours? That is totally unacceptable.

Why were you flat on your back to be intubated. You should have been on a left lateral tlit - the theatre table should have been positioned like that. There are failed intubation procedures to keep you and babies oxygenated. did they explain that?

Clinical governance facilitator will review casenotes etc and recommend changes. That is commonplace for all clinical risk incidents. That should have been done by now in a case like this!!!! That information should have been available for you today IMO. Have they accepted responsibility? Have they apologised?

Sorry for the questions - I would have thought that they would have been prepared for you with more information today

suedonim Sat 30-Apr-05 00:34:46

Bubble, I'm not really one to swear but shit, shit, shit. Don't know what else to say.....sorry.

bubble99 Sat 30-Apr-05 00:53:02

mears, We're having a further meeting anyway after they've investigated the issues/questions raised by us today. My 24 hour urine collection showed 0.3mg Protein which the consultant said was normal. I showed her the lab report form which had an asterix next to the reading denoting 'high'. And no, I don't feel satisfied with their take on the whole situation. Regarding the bleep holder, they said today that this role will be reinstated. We want to know where the funding will come from, I don't want to find out that they've cut back on other esential resources to pay for it.

The consultant anaesthetist was a complete 'See You Next Tuesday' Arrogant does not begin to describe him and he was on the defensive from the word go. He was last on the scene yet he was telling me what had happened before I was given the GA so it basically comes down to my word against that of his staff. I was bagged via a mask while they were waiting for the anaesthetic senior reg to come and intubate me and my sats dropped to 82% for a significant amount of time. Not good. They have come up with recommendations but after two and a half hours of hearing how our healthy little boy died we decided it would be best to reconvene. Make no mistake-they know they F***d up but despite their promises to have a 'full and frank' discussion I was not told about inadequate staffing levels, for example. I got the impression that they would put their hands up to anyhting I'd noticed was amiss but that they wouldn't bring it to our attention if we hadn't. Not full and frank then, is it?

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