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Baby boy dies after five hours of delays and blunders at St George’s hospital

Mark Bowman
09/02/2017
A PREMATURE baby died after a shortage of doctors and midwives at one of the country’s biggest hospitals resulted in five hours of missed opportunities to save his life.

Huw Stewart was delivered stillborn at St George’s hospital, Tooting, after staff initially failed to realise his mother Philippa Stewart had gone into labour at 27 weeks. An internal investigation found the “delay in delivery” and failure to act on his weakening heartbeat was the “root cause” of death.

"Junior midwife left to care for four women after locum doctor walked out over pay"

The shocking report, passed to the Standard, said a junior midwife had been placed in an “untenable situation” by having to look after Mrs Stewart and three other women in labour at the same time, meaning their safety “was compromised”.

The midwife had to interrupt an operation in a bid to summon urgent help after the baby’s heartbeat could not be detected, the report said. It also revealed that a locum doctor had walked out — without telling colleagues — after discovering he was to be paid less than he thought.

Details of the case come as the Royal College of Midwives this week warned that NHS maternity services were “reaching crisis point”, with England short of 3,500 midwives.

St George’s, which features in the TV documentary series 24 Hours in A&E, was last year rated “inadequate” by NHS inspectors, though its maternity department was praised.

"Couple offered no grief counselling and St George’s took a year to admit blame"

It offered no bereavement counselling to Mrs Stewart and husband Jonty and delayed accepting blame for almost a year. Six hours after it was approached by the Evening Standard last week, Mrs Stewart’s solicitors were told that “liability is admitted” and that the trust was preparing “to apologise for this extremely distressing incident”.

Mrs Stewart, 34, told the Standard:

"I’m forever changed by what has happened.  I’m definitely not the person I was before we lost Huw.

“I needed someone to say sorry, that we did this terrible thing. That is all I really wanted in the end. It’s sad it has taken a phone call [by the Standard] to progress things. It’s coming up to Huw’s  birthday and it’s still unresolved. We  can’t focus on moving on. I can’t even  think about having another baby."

Mrs Stewart, who worked as a occupational  therapist with children damaged  at birth, had been admitted to St  George’s on February 13 last year with  abdominal pain.

She was kept in overnight and her  waters broke about 8am the next day.

The internal review said that delivery  should have been recommended at 9.15am. By 10am, “immediate delivery”  was required, but this did not happen  until 2.11pm.

The report said: “Each time the  patient was reviewed after 09.15 there were missed opportunities for intervention.

“The root cause of the stillbirth was  the delay in delivery of the baby following  incorrect classification of a pathological and preterminal CTG [cardiotocography heart rate scan].”

Mrs Stewart said:

"We didn’t know it  was chaotic. We just knew people were  not there. I tried a number of times to  tell them things were wrong. On my  [medical] notes, they label me as anxious,  which is quite upsetting.

"I guess the first time we knew things  were going terribly wrong was when  my waters broke and there was no one  around. My husband had to stand in  the corridor and shout to get help."

Mr Stewart, a Metropolitan police  civilian crime scene examiner, suffered a stroke 10 weeks after Huw’s death. He was saved by St George’s.

Mrs Stewart, said.
"That is the whole irony of what happened  to us,” Mrs Stewart, an Australian,  said. “It would be easy for us to say  St George’s is a terrible hospital and tell  people to never go there.

"What it shows is what happens when  you have a well-funded service with staff  on hand. In one hospital there are two  completely polar opposite extremes."

The couple have moved to Melbourne  for a “fresh start”.

Their lawyer, Mark  Bowman, of Fieldfisher, said:

"The NHS  keeps publicly promising better transparency  for people experiencing such  tragedy.

"Philippa and Jonty had experienced  the worst pain possible and were not  given the care and compassion any of  us would hope for."

Professor Andrew Rhodes, medical  director at St George’s, said:
"This is a very sad case, but one we are committed to learning lessons from."

This story was orginally report on by Ross Lydall, Health editor and published in the Evening Standard on Wednesday 8 February 2017

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