‘My baby was stillborn but if mistakes hadn’t been made he’d be alive’
A GRIEF-STRICKEN mother says she “truly believes” her baby son would still be alive today if serious mistakes had not been made in his care.
Kate Southcombe, from Porth, Rhondda, said she has suffered with anxiety ever since she gave birth to stillborn Reuben Pugh at the Royal Glamorgan Hospital, Llantrisant, in 2017.
Following an investigation by an independent panel of experts, several “major” failings were identified in the treatment given to the 26 year old and her unborn baby which may have altered the tragic outcome.
The panel said that while there was “clear evidence” that Kate had a highrisk pregnancy due to her diabetes, it was not recognised by staff or communicated with the mother.
They also found “limited” documentation of Kate’s deteriorating diabetes picture or a reduction in the baby’s growth, which meant the panel could not see whether an enhanced plan to monitor the pregnancy more frequently was ever created.
They also noted that the baby’s growth measurements were “incompletely documented” on the customised baby growth chart.
Other less serious failings identified included the lack of follow-up when Kate failed to attend a glucose tolerance test (GTT) and little evidence of bereavement support offered to her.
“I was told only a week before that I was going to give birth to a healthy baby boy,” said Kate.
“I truly believe things would have been different if the care had been better.
“The first I heard about the baby’s growth reducing was when the panel’s report came out.”
Kate said she had a scan at 16 weeks to find out the baby’s gender early. It discovered that the ventricles in the unborn child’s brain were slightly dilated which could indicate a chromosome disorder.
“Because of that I was under fetal medicine. I was also consultant-led because of my diabetes,” she added.
But the panel’s report states that the consultant obstetrician described Kate’s diabetes as “well-controlled” at 28 weeks gestation.
The reports adds: “After this gestation the records do not demonstrate any obstetric ownership of the care to include discussion and input from the fetal medicine unit and diabetic team.”
Kate said while she was being regularly scanned or given tests at various different clinical sites, including the University Hospital of Wales and in Bristol, she said there were a lack of joined-up care between the medics.
She added: “Throughout my pregnancy there were never really concerns that we wouldn’t have a healthy baby.
“In fact a week before I had him the consultant in fetal medicine said to me: ‘You’re expected to have a healthy, normal baby’. Those were his exact words.”
However a scan on the same day as her appointment with the consultant revealed that there was abnormal blood flow through the baby’s umbilical cord – something Kate claims was never relaid to her.
“I then went into hospital with reduced fetal movements and a scan showed there was no longer a heartbeat,” she recalled.
“I just remember shaking and crying – I couldn’t even speak. I was taken into a little room and given the option of a C-section or a natural birth. I chose to go natural.”
One of the things Kate said went “under the radar” in the panel’s report was her experience of the day she was induced and the poor attitude of midwives she alleged she experienced.
“We were in the middle of the labour ward so you could hear all the other babies being born. There was no sympathy at all for our situation,” she said.
“And we couldn’t have access to the ‘cold cot’ [a cooling mattress that stop the baby’s body deteriorating] which meant that we couldn’t spend long with our son and properly say our goodbyes.” Kate – who has two other children called Zachary, aged six, and Noah, three – said she was given counselling after the traumatic ordeal and was constantly on edge during her pregnancy with Noah.
“I had post-natal depression and I couldn’t sleep because I was constantly worrying [about Noah],” she said.
The panel’s thematic report into stillbirths, which was published on Tuesday, October 5, found that one in three babies stillborn at the Royal Glamorgan Hospital, Llantrisant, and Prince Charles Hospital, Merthyr Tydfil, between January 1, 2016, and September 30, 2018, may have survived had it not been for serious clinical mistakes.
Their investigation found “major” failings in 21 of 63 cases at two hospitals run by Cwm Taf Morgannwg University Health Board.
The panel’s review was commissioned after the Welsh Government placed maternity services at the health board into special measures in 2019.
In a further 37 (59%) cases the review said one or more minor mistakes happened and lessons could be learned from 48 (76%) cases.
There were just four cases (6%) where the panel found no issues with the care received.
The report also highlighted how the views of expectant mothers were often ignored by medical staff and they felt they could not share their concerns.
In response to the report Greg Dix, executive director of nursing and midwifery at Cwm Taf Morgannwg University Health Board, said: “Losing a baby is tragic for any family and our sincere and heartfelt condolences go out to all of our families who have lost a child to stillbirth in our health board.
“We will never forget the tragedies suffered by women, their families, and our staff and the learning from these cases is the foundation on which we are building our improvement plans.
“Our health board is continually working to understand and reduce our stillbirths as a matter of priority and we are already making significant progress.
“The improvement work detailed in the report is a demonstration of our continued commitment to ensure our stillbirths are as low as they can possibly be to avoid any family having to face unnecessarily such a tragic event.”