‘We feel like something is missing from our lives all the time’
A heartbroken couple whose daughter was stillborn believe she would still be alive today had there not been major failings in their maternity care, as Mark Smith reports...
A HEARTBROKEN couple whose daughter was stillborn believe she would still be alive today had there not been major failings in their maternity care.
Pippa Howells was delivered stillborn at Prince Charles Hospital in Merthyr Tydfil on February 3, 2016, leaving her parents Gareth and Sammy “completely devastated”.
After feeling unhappy with the care they had received in the latter stages of Sammy’s pregnancy, in particular when it came to what they say were inconsistencies in the dates they were told Pippa’s heart had stopped beating, they decided to ask for their medical notes and investigate the matter further.
After making a complaint to Cwm Taf Morgannwg University Health Board and waiting years for concrete answers, an independent panel set up by the Welsh Government to oversee improvements in the health board’s two maternity units looked into the care given to the family, along with 63 other stillbirths between January 2016 and September 2018.
They found that vital scans were not carried out beyond 36 weeks of Sammy’s pregnancy despite concerns the baby was not “growing as well as expected”. They said this was a “missed opportunity” to plan an earlier birth.
The independent panel also discovered that the ongoing management of the pregnancy should have been overseen by a senior obstetrician in line with national guidance.
While the stillbirth was reviewed and recorded in the health board’s internal systems, the panel’s report found it was “not performed to a high enough standard” and did not identify issues that were spotted in the panel’s own review.
In total, the report found 13 socalled “modifiable factors” where care fell below expected standards, including four major ones which “contributed significantly” to the poor outcome.
With different management, the panel concluded that the outcome could have been altered.
“We feel like something is missing from our lives all the time; that something’s always not quite right. Every birthday, every Christmas, every first day of school we remember her. Not a day goes by without us reliving that day,” said Gareth, 46, from Fochriw, Caerphilly.
“It was a bittersweet moment when we were given that report. On the one hand it brought everything back, but at least we knew we weren’t at fault, because for years Sammy had blamed herself for what had happened.”
Gareth, a dad-of-six, said wife Sammy, 30, had gone through a relatively straightforward pregnancy until 36 weeks when the symphysis fundal height measurements identified that Pippa was not growing as much as hoped.
However, the panel found no follow-up growth scans were arranged by staff.
At 37 weeks Pippa was in the breech position and the decision was made for Sammy to have a planned c-section at 39 weeks. But at 38 weeks and four days Sammy reported feeling no baby movements and visited Prince Charles Hospital. Maternity staff were unable to find the baby’s heartbeat and this was further confirmed in an ultrasound scan.
The following day Sammy underwent the c-section knowing that her baby daughter would not be alive upon delivery. She spent two precious days in the hospital with Pippa to say her goodbyes before she was handed over to nurses. Gareth admitted that the pair were left traumatised by the horrific ordeal. “Sammy pretty much doesn’t go anywhere on her own. I gave up work to look after her,” he added. “But hopefully sharing our story will encourage more families to come forward and tell their stories.” The report added that as the placenta was not sent for examination it was “difficult” to confirm the reason why Pippa’s heart stopped beating. “We would like to reassure [Sammy] that there was nothing you did that contributed to the outcome of your pregnancy,” the panel’s authors stated.
Part of the independent panel’s investigation into Cwm Taf Morgannwg maternity services looked at 63 stillbirths between January 1, 2016, and September 30, 2018. It discovered that 21 (33%) of them had at least one “major modifiable factor”, meaning the stillbirth could potentially have been avoided.
More than half (59%) of the 63 had at least one “minor modifiable factor” while in three-quarters (76%) of them “wider learning” was required. In only four of the 63 stillbirths the panel found no modifiable factors.
The panel also discovered that “areas for learning” were identified in 59 of the 63 episodes of care reviewed.
In the 21 cases where a “major modifiable factor” was found inadequate or inappropriate, treatment was identified in 17 of them while diagnosis or recognition of high-risk status was identified in 14.
In those episodes of care where inadequate or inappropriate treatment was identified, fetal growth, fetal movement, and fetal heart monitoring were all described as “notable issues”.
The panel found four major themes to these overall failures in care including: failure to listen to women; failure to identify and escalate risk; inadequate clinical leadership; and inappropriate treatment leading to adverse outcomes.
In response to Gareth and Sammy’s ordeal, Cwm Taf Morgannwg UHB chief executive Paul Mears said: “Losing a baby is tragic for any family, and our sincere and heartfelt condolences go to Mr and Mrs Howells on the loss of their daughter, Pippa.
“During a very difficult six years following the loss of baby Pippa, we have responded diligently and have done our very best to address all of Mr and Mrs Howells’ concerns and queries about the care provided throughout Mrs Howells’ pregnancy.
“As well as an internal review of Mrs Howells’ care, there has been an independent assessment by the Independent Maternity Services Insight Panel (IMSOP) which is commissioned by Welsh Government to work with us to improve maternity services at Cwm Taf Morgannwg, to help give Mr and Mrs Howells the answers they have sought. We continue to extend the offer of support to the family as they grieve for their daughter.
“As a health board, we remain firmly committed to continually improving our maternity and neonatal services, and to making the changes that are so critical to improving our services for the future. We offer our heartfelt sympathy once again to Mr and Mrs Howells as they continue to come to terms with the loss of their daughter.”
In 2019 an investigation by the Royal College of Obstetricians and Gynaecology (RCOG) and the Royal College of Midwives – prompted by a consultant midwife who was concerned by an apparent under-reporting of serious incidents, including deaths of babies – unearthed a series of wide-ranging concerns.
They discovered that maternity services at both the Royal Glamorgan Hospital in Llantrisant and Prince Charles Hospital were “under extreme pressure”, “dysfunctional”, and were putting families and babies at risk.
As a consequence the health board’s maternity services were placed in special measures by the Welsh Government in April 2019 – the highest level of government control – and the independent panel was set up to oversee improvements.
Reports from the panel have been published ever since which show that improvements are being made.
We remain firmly committed to continually improving our maternity and neonatal services
Cwm Taf Morgannwg UHB chief executive Paul Mears