In its own internal investigation, the hospital highlights a serious breakdown in procedure. Maternity staff lost contact with the foetal heart rate in a series of errors and missed that it was dangerously low, resulting in a delay in delivery Alice.
Sarah Tobin, who is now 34, had a good first pregnancy with very little complication. She was admitted at 39 weeks onto the labour ward at the Royal Sussex County Hospital in Brighton at 3am in the morning. Being low risk, she went through with her plans to have a water birth. She was 5cm dilated. In the birthing pool, regular checks of the baby's heart rate were normal. When she was around 8cm dilated, Sarah got out of the pool for a newly attending midwife to perform a Doppler scan, when it was discovered the foetal heart rate had slowed. Sarah was moved to another room to move the labour along.
When the midwife tried to put on a continuous foetal heart rate monitor, the first machine didn't work. When they got the second machine to work, there was slight concern that during contractions the baby's heart rate was dropping.
Sarah had become very tired but continued to push and although the midwife noted they were over the recommended time for pushing but decided not to call a consultant as the baby was so close to delivery. The midwife also noted that the baby's heart rate was no longer dropping during contractions.
The midwife then checked Sarah's pulse at her wrist and realised it was the same as the baby's heart rate, meaning the machine was measuring the maternal heart rate and not the baby's. When this was corrected and the baby's heart rate was monitored, it was very low. The alarm was sounded and the birth was accelerated through stretching and an episiotomy and eventually Alice was born, but she was blue and not breathing. Alice was kept in intensive care but had suffered brain damage. The decision was made five days later to cease intensive care and she died.
In situations like this, protocol suggests using foetal scalp electrodes to measure foetal heart rate when CTG isn't working. This was not done, nor was obstetric opinion sought in response to 'suspicious' tracing. One of the midwives involved did not know how to use the new monitor that was on trial. It is usual to monitor the maternal heart rate at the beginning to ensure that the machine is picking up the baby's heart rate. The student midwife involved had been working for 16 hours.
Sarah and Dave Tobin now have a baby boy Caspar, who is 9 weeks old, born 7 days after what would have been Alice's first birthday.
Although they're still grieving, they made the decision in the hospital with Alice that they would fly to Thailand immediately after the funeral to find some space. They also made the decision to get pregnant as soon as medically safe, and Sarah got pregnant very quickly.
Sarah did a lot of work with therapy, including reiki, acupuncture and a new technical called Emotional Freedom Technique, which taps on the body's meridians to let her revisit the scene of Alice's death but allows her to let go of the pain. They also fundraised £12,000 for the Trevor Mann Unit that kept Alice alive for 5 days.
Iona Meeres-Young, the Tobin's lawyer, said:
"The hospital have carried out an investigation and identified serious failings, but Sarah and David are still left with unanswered questions. The litigation will provide them with those answers. The Tobins have bravely shared their experience in the hope that it raises awareness and drives up the standard of maternity care."
Sarah Tobin said:
"I felt huge guilt when I left the hospital with Casper because it wasn't something I was able to do with Alice. The pregnancy was very traumatic but we kept ourselves focussed on the blessing that was him growing. I asked for an elective caesarean because I was terrified of going through another natural birth and that was a very joyful experience for both of us. Control was taken away from us during Alice's birth but the caesarean let us take back control of Casper's birth.
"We still have a lot of pain and we still don't know what happened. It will take two years before I get the answers. Fieldfisher are waiting for expert witness to pursue a claim. It's hard to accept that there were so many mistakes. I counted seven. If there had just been one, Alice may still be alive.
"One of the protocol issue raised in the hospital investigation was a failure to bring in 'fresh eyes' to assess the trace. Personally, I feel that's a lot to ask of the midwife to demand that. She should be given the support without having to ask. I didn’t see a consultant the whole time I was in labour."
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