Stillbirth at Kings College Hospital due to failure to react to abnormal fetal heart rate
At 37+3 weeks, PC attended the Maternal Assessment Unit reporting reduced fetal movements. A doctor recorded a CTG as 'suspicious' and PC was transferred to the Labour Ward for further assessment before being discharged back to midwifery care.
At 40+3 weeks, PC attended hospital for a membrane sweep. The fetal heart rate was recorded three times, and decreased each time. The midwife reassured PC that everything was normal and booked her in for a further sweep two days later. No advice was given if PC continued to experience reduced fetal movements.
Two days later, PC, reported feeling unwell, and that fetal movements had reduced from the previous day. A sweep was not attempted as the midwife could not find a fetal heartbeat and PC was sent to the Labour Ward. She reported a worsening headache, epigastric pain on the right side of her abdomen and oedema in her legs and feet.
On the Labour Ward, an attempt was made to auscultate the fetal heart rate with a sonicaid, but no heartbeat was heard. An ultrasound scan confirmed an intra-uterine death.
Despite opting for an immediate induction, PC then had to undergo a 37-hour labour to deliver her stillborn son.
A Serious Untoward Investigation (SUI) Report was prepared by the Trust which noted the root cause of the baby's death to be 'failure to recognise and act on an abnormal fetal heart rate in a post-date baby'. It also identified care and service delivery problems:
a. Fetal tachycardia at 40+3 weeks. No further monitoring
b. No action taken when post sweep FHR remained borderline tachycardic
c. Standard of fetal auscultation process in antenatal clinics
Arti wrote to the Trust, which admitted breach of duty, but not causation. Investigations commenced and, despite providing the Trust with expert evidence, no response on causation was forthcoming.
Pre-issue settlement negotiations were entered, however, and the case settled just before limitation expired.
At the end of the case, PC said:
"My experience liaising with Fieldfisher was always very good. At all times they kept me up to date and informed me of the processes along the way. They were very attentive, sensitive and professional. This helped me immensely, especially due to the nature of my case. I felt that they actually cared about me, what I had been through and my well-being.
"My contact was Arti Shah and she was brilliant. She was always contactable, advising or informing me of my options. I would highly recommend Arti and Fieldfisher, because my experience with them was of a high standard with due care and attention taken at all times."
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