BABY DIED AFTER 27 DIFFERENT MISTAKES WERE MADE BY NHS STAFF BEFORE HIS BIRTH:
KARA JONES was over the moon when she found out she was pregnant with her first child.
She could not contain her excitement at the thought of becoming a mum and meeting her baby boy.
But what should have been the happiest time of her life turned out to be the most traumatic after her son Arthur tragically died just 24 minutes after he was born.
It was later discovered that a staggering 27 mistakes were made during her pregnancy and labour which were likely to have contributed to the tot’s death.
“I never met him, I never held him,” said Kara, who has suffered from post-traumatic stress disorder ever since.
“You pay your taxes and you think you’re going to have the best care, but it didn’t work out that way for me.”
Kara, from Tre’r Ddol, Ceredigion, was receiving care at Bronglais Hospital in Abersytwyth during her pregnancy.
But because she had type 1 diabetes she was deemed a “high risk” case and had to pay regular visits to see specialists at Glangwili Hospital in Carmarthen – a five-hour round trip in the car.
It was there that Kara, 27, along with partner Sam Penfold, 29, had concerns about their care and the lack of consistency around it.
“I was beginning to suspect that things were being kept from us. Sam and I both had growing concerns about our baby,” said Kara, who suffered with terrible swelling in her feet during the latter stages of the pregnancy.
“[Two days before the delivery] I told the midwives that I was worried as I hadn’t felt our baby move at all that day.
“I was told that movement was picked up on the scan, and often during the last few weeks of pregnancy mothers-to-be don’t feel as much movement anyway.
“This put my mind at ease a little bit, but I knew something wasn’t right.”
On March 12, 2017, Kara was prepped for a C-section.
But while she was in theatre ready to be given a spinal anesthesia, she had a strong feeling that the baby needed to be delivered straight away.
“I begged for them to get him out, but I felt like I wasn’t being listened to,” she added.
After delaying the initial operation, Kara was rushed back into theatre hours later – this time under general anaesthetic – for another attempt at a C-section.
“The first thing I remember after the operation was waking up in the theatre room and asking Sam if our baby was OK, when he replied, ‘No, he’s gone’,” she recalled.
“For some reason I wasn’t
shocked. What surprised me most was that I’d survived myself.”
The following day, Kara said she was placed on the labour ward surrounded by the sound of crying babies, making the situation more heartbreaking than it already was.
She said: “I stayed up most of the night crying with Sam and a midwife, feeling like my soul had been ripped out of me.”
An internal report by Hywel Dda University Health Board, which runs Glangwili Hospital, uncovered a catalogue of failings into their care.
These included numerous failures to act on abnormal scan findings, and a failure to carry out the delivery sooner.
The couple had specific concerns over the behaviour of the consultant Alan Treharne who was on call during that weekend.
An investigation by the General Medical Council (GMC) came to the conclusion that the doctor’s management of Kara fell seriously below the standard expected of a reasonably competent consultant in obstetrics.
However, no restrictions were placed on his practice. He was given a formal warning effective between June 26, 2018, and June 26, 2019.
A statement by the GMC read: “Dr Treharne failed to obtain an adequate clinical history for the patient, failed to adequately assess readings of fetal heartbeat and contractions, did not arrange continuous monitoring, did not appreciate the full significance of the clinical risks and wrongly concluded that there was no immediate urgency to deliver the patient’s baby on March 12, 2017.
“This conduct does not meet with the standards required of a doctor. It risks bringing the profession into disrepute and it must not be repeated.”
Kara and Sam, who have since had two more children called Ralffi and Dyfi, said they wanted to highlight their harrowing ordeal to prevent it from happening again.
Sam said: “We felt like our concerns were completely ignored. The midwives did everything they could to try and convince the consultant to deliver the baby sooner until they were blue in the face.
“We are very lucky to have two other children in our lives now, but we will make sure they never forget Arthur.”
And Kara added: “With each day that goes by, I find myself hurting because it is another day longer since he was in my tummy, yet I am excited because it’s a day closer to meeting him again.”
In response, director of nursing, quality and patient experience for Hywel Dda UHB, Mandy Rayani, said: “On behalf of Hywel Dda I wish to offer our sincere condolences and apologies for the distress experienced by Ms Jones and her family.
“A thorough investigation was undertaken by the health board as well as the GMC. This resulted in a number of recommendations to change procedures and clinical pathways.
“Additional learning and training for the whole multidisciplinary team has taken place across the health board area. We wish to provide assurance that all of these recommendations have been implemented.”
You pay your taxes and you think you’re going to have the best care, but it didn’t work out that way for me KARA JONES