Royal Surrey County Hospital, Guildford, have been ordered to apologise and pay compensation after staff made a catalogue of errors leading to a healthy baby being stillborn whilst overdue for delivery.
Hamish Dobson was stillborn in April 2014 at full term after what staff at the hospital had misinterpreted as being a perfect pregnancy. His father, Max Dobson, explained “we were so excited and never imagined anything could go wrong – one doctor even described the pregnancy as boring, in a good way. Our son was past his due date and ready to be born, when my wife noticed she hadn’t felt him moving that day. We went into hospital just for peace of mind only to receive the unimaginable news that no heartbeat could be found and our whole world collapsed. Over the following days my wife had to go through the unimaginable ordeal of giving birth to our dead son. The staff who supported us through this were amazing and we are incredibly grateful to them”.
“Our consultant told us that stillbirth was very sad but just something that happened for unknown reasons, and there was nothing anyone could have done. It was only later that we found out this was completely untrue and like in most stillbirths that happen at full term, there were errors and opportunities to prevent this devastating tragedy. They should have been bringing life into the world, not death”.
Multiple service failures
Following two years of delays, the Ombudsman issued a report concluding that “aspects of Mrs Dobson’s care fell so far below the applicable standards and established good practice that they were service failure”, and led to “missed opportunities to achieve a better outcome”.
The Ombudsman found that Mrs Dobson should have been told to report any change in fetal movements to the hospital, but the advice Mrs Dobson’s midwife gave was “wrong” and that Mrs Dobson would have attended the maternity unit earlier had she been given the correct advice. A second “significant opportunity lost” was when the same midwife failed to refer Mrs Dobson for a scan when measurements indicated that Hamish was not growing properly.
On her due date, Mrs Dobson had attended an antenatal appointment and her consultant instructed a junior doctor to send her for monitoring due to her rising blood pressure. However, the junior doctor failed to do so for unexplained reasons and the monitoring never took place. The Ombudsman concluded that the doctor failed to comply with Good Medical Practice’s requirements. The pathologist who performed the post-mortem confirmed that Hamish would have been in distress at the time, yet Mrs Dobson had been dismissed without monitoring and Hamish died two days later.
The Ombudsman identified a number of other service failures throughout Mrs Dobson’s pregnancy, including that she was placed on the wrong care pathway from the outset; and the hospital failed to ensure that risk assessments were undertaken, findings acted upon and documented.
The post mortem revealed that Hamish was a healthy baby who had died from a lack of oxygen, with the underlying cause unknown but problems identified with the placenta. Although the Ombudsman decided that it could not conclusively say whether or not Hamish’s death would have been prevented if not for the failures, due to a lack of evidence about Hamish’s condition, it noted several missed opportunities that could have saved his life and Mr and Mrs Dobson are in no doubt that his death was preventable. “We have spoken to a number of world renowned experts in the field to understand what happened to Hamish, including Professors of Fetal Medicine at two leading London hospitals. Both were clear that babies do not simply drop dead in the way that Royal Surrey continue to claim to us, and one described Hamish’s death as “totally avoidable”.
Mr Dobson were critical of the hospital’s response to the tragedy and lack of investigation. “Sadly because Hamish never took a breath, he had no human rights and they tried to sweep him under the carpet. The coroner was not permitted to investigate and the hospital insisted that Hamish did not even qualify for a Serious Incident investigation, despite being a healthy baby who would undoubtedly have lived had he only been monitored properly and delivered rather than allowed to go overdue”. We were lied to about a test result that had never been performed and when we asked to see the medical records, we were sent a copy with the key pages of evidence missing. They did however include an inappropriate letter congratulating us on the birth and explaining what a ‘delightful’ and ‘precious’ time we should be enjoying.”
After Mr and Mrs Dobson complained, the hospital acknowledged some of its failings in an internal report. However, the root cause of the failures were never investigated and statements were not taken from staff until 4 months after Hamish’s death, at which point the staff involved claimed to be unable to recall the incidents. The hospital eventually admitted that its investigation “was not thorough enough to establish the facts of the case”.
The Ombudsman reported that “It was evident from our review of the trust’s complaint handling that there were numerous inconsistencies and contradictions in the information they provided to Mr and Mrs Dobson”. The Ombudsman found maladministration in the Trust’s approach to remedy in their complaints handling and ordered the Trust to make a payment in recognition of the injustice caused by the failures. Mr and Mrs Dobson have donated the full amount to the charities Tommy’s and Sands, which fund research to save babies lives.
Mr Dobson said “We understand that doctors are human and can make tragic mistakes. But what is unforgivable is to fail to learn from them and put their own interests ahead of patient safety. It is now two years after Hamish’s death and Royal Surrey have continued to put babies at risk by failing to implement even the most basic measures to prevent stillbirth, such as plotting babies growth on charts for mothers classified as ‘low risk’. There are a lot of amazing doctors and midwives working at the hospital, but they need to be supported with the tools to do their job safely and a culture of investigating and learning from mistakes, so no more babies die unnecessarily”.
A national problem
Hamish was one of 3,452 babies stillborn in the UK in 2014, almost ten every single day. Earlier this year the UK was ranked 114th internationally by the Lancet for its lack of progress in addressing stillbirth, with other developed countries such as Netherlands having achieved rates 40% lower.
Stillbirths like Hamish’s are repeated daily up and down the country. In November 2015, the MBBRACE Confidential Enquiry into healthy stillborn babies at full term found that in half of those stillbirths there were critical gaps in care and opportunities to save the babies life. In nearly two thirds of cases reviewed national guidance for screening and monitoring the growth of the baby was not followed, and in a third of cases with reduced fetal movements there were major issues with the quality of care. Despite this, for three quarters of stillbirths no local review of the care had been carried out.
Mr Dobson attributes the lack of investigation and action to a misplaced fatalism around stillbirth. “There is a taboo around stillbirth and far too many healthcare professionals still don’t realise that many of these deaths are preventable. What gives us hope is the inspiring individuals around the country who are already using modern techniques to identify the babies at risk more accurately and save lives that others would have written off. We need to learn from them – it’s too late for Hamish, but it’s not too late to do the right thing for other babies and families.”