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