A hospital that was at the centre of a major inquiry into unsafe maternity care five years ago is facing new questions over its safety after bosses admitted a baby boy would have survived if not for mistakes by hospital staff.
Jenny Feasey, from Heysham in Lancashire, is still coming to terms with the loss of her son Toby who was stillborn at the Royal Lancaster Infirmary, part of the University Hospitals of Morecambe Bay Foundation Trust in January 2017 after a series of mistakes by staff who did not act on signs she had pre-eclampsia.
Jenny, 33, has backed The Independent’s campaign for improved maternity safety and called on midwives to learn lessons after what happened to her family.
She added: “This was an easily avoidable situation. They just didn’t piece it together, all they had to do was carry out a test and I lost my son because of it.”
The Morecambe Bay trust was heavily criticised for its poor maternity services by an independent inquiry in 2015 which concluded a ‘lethal mix’ of failings at the trust’s Furness General Hospital had caused the avoidable deaths of at least 11 babies and one mother.
Now it has emerged an inspection of the unit by the Care Quality Commission has found similar concerns five years on.
A report by the watchdog, published in March, found a deterioration in culture at the unit adding: “Not all staff felt respected, supported and valued. Whilst we found that staff were focused on the needs of patients, some staff raised concerns to us about the culture within the services.
“Staff morale was low and there were strained relationships between clinicians and nursing staff.”
The trust has said it has taken action to improve the situation.
In baby Toby’s case, the trust has accepted he would have survived if a routine lab test had been requested by a midwife after a dipstick test at 35 weeks revealed significantly raised protein levels in Jenny’s urine, a key symptom of pre-eclampsia.
Pre-eclampsia is a condition which occurs during pregnancy and can be extremely dangerous to both the unborn baby and mother.
The laboratory analysis of the urine sample would have triggered involvement from a doctor and frequent monitoring of both Jenny and Toby.
Jenny’s family had a history of pre-eclampsia but it was wrongly documented in her notes that this was her grandmother and not her mother.
Jenny said: “Daniel and I had been trying for a baby for a couple of years before I fell pregnant with Toby so we were beyond thrilled to finally be expecting. Looking back there were signs that something was not right even before the protein was found in the urine sample.
“At times I had high blood pressure and I also suffered with severe headaches and vision problems, which were investigated with an MRI scan. These are symptoms of pre-eclampsia yet no one put the pieces together.”
On New Year’s eve 2016, Jenny woke up with pain in her back. She called the community midwife but was told Toby was “just a big baby” and to take paracetamol every four hours to see if the pain subsided, which it did.
On 5 January she attended a routine appointment with her midwife who found her abdomen was much smaller than two weeks previously. They could not find Toby’s heartbeat.
The Royal Lancaster Infirmary confirmed Toby had died and Jenny had to be induced to deliver him.
“After I lost Toby when I met the consultant the first thing he said to me was ‘I am sorry we failed you,” Jenny said but when she raised concerns she was not listened to adding: “It felt as if they were trying to get out of admitting anything and made it sound almost like it was my fault. That is what made us decide to go to solicitors.
“Maternity units have to learn from one another. All we wanted was an official apology and to know they were going to make changes to stop it happening again.”
Jenny is keen for other maternity units to learn from what happened to Tony.
“Midwives need to not take anything for granted and listen to a mothers intuition. Just because a piece of paper says they are low risk it doesn’t mean things can’t go wrong. The consequence for their error in judgement is momentary for them but for us it lasts a lifetime.”
The trust has admitted negligence in the care of Jenny and Toby as part of a court case brought by law firm JMW.
Jenny and her husband Daniel have gone on to have children Harper, aged two and Orion, aged six months. They described the care by the hospital as excellent
Jenny added: “The good care I received during my pregnancies with Harper and Orion make it even more apparent that Toby would be here if he had been afforded the same standard. That’s absolutely heartbreaking and while nothing can be done to bring him back I would like lessons to be learned on a national level so that other families don’t have to go through what we have.”
The case has emerged as maternity services across the country are under the spotlight.
Two fifths of maternity units are rated requires improvement for safety by the CQC.
The family and their law firm have backed The Independent’s campaign to reinstate a national maternity safety training fund for the NHS which helped train 30,000 NHS staff before it was scrapped after just one year.
Lucy Mellor, clinical negligence solicitor at JMW, said: “The maternity safety training fund has been found to enhance the skills, knowledge, and awareness of staff, and improve multi-professional working and communication. Each of these were either diminished or absent in Jenny’s case and the theme has sadly been consistent across hundreds of other cases we have dealt with.
“The maternity safety training fund needs to be reinstated as a matter of urgency as an effective and proven means of reducing avoidable death and severe harm to both mother and baby.”
Sue Smith, chief nurse and deputy chief executive at University Hospitals of Morecambe Bay told The Independent: "Toby's case is a very tragic one and our condolences go out to Jennifer. While we have written to her and admitted liability in this terribly sad case - it is still awaiting a final settlement.”
She said the CQC carried out an inspection after anonymous concerns were raised with the watchdog in December 2019.
She said the finding by the inspectors that staff did not feel supported and some were concerned about the culture was concerning.
She added: “We have since implemented an enhanced package of cultural support to the service. Cultural change is generally accepted as being an area that is not often rectified quickly. However, we are confident that the additional investment that the trust board have made into greater support for this team will accelerate the changes needed.
"The CQC did not take any formal action."