Dad-to-be ‘was told his stillborn baby was fine’
AFATHER- TO- BE was told his newborn baby was ‘fine’, only to find out that she had in fact been stillborn, an inquest heard.
Baby Evelyn Davies died at Stepping Hill Hospital in November 2018 after her mum, Elizabeth Davies, went into early labour when 26 weeks pregnant.
An inquest at Stockport Coroners’ court heard how there had been a lack of clarity regarding Evelyn’s death.
It had been unclear whether she had been stillborn or had died shortly after being delivered via caesarean section.
Mrs Davies, from Marple, had been advised to go to hospital after developing stomach pains and passing blood clots on the evening of November 10, 2018.
She and her husband, Major Matthew Davies, were admitted to the maternity unit at Stepping Hill for further assessment.
Major Davies said doctors and midwives did not share any concerns about the baby’s wellbeing when tracking her heartbeat with a CTG scan.
Mrs Davies was given steroids and nifedipine to delay the onset of full labour, yet her contractions persisted, the inquest heard.
Doctors decided that the baby would need to be delivered via a category 2 emergency C-section under general anaesthetic.
Her husband was put in a room on his own while Mrs Davies was taken down to theatre.
“I was not told about any of the risks or concerns that they had,” Major Davies told the court.
A short time later a midwife, Stephanie Bray, told Major Davies that his baby had been born.
He added: “Midwife Bray came to tell me that baby had been delivered and that mother and baby were both fine. She said the baby was perfect. I was told that they were just helping the baby breathe and that I would probably see her when she was taken through to the ward. Then I was left.”
A doctor then informed Major Davies that his daughter was being resuscitated, and asked for permission to halt the resuscitation attempt.
“Obviously we were not expecting Evelyn to be born at that stage,” he said.
“I had been sitting in the room thinking [we had] a new baby. I was sitting there taking stock of that and I was waiting to see my daughter.”
He added: “Clearly that was a big shock.”
Major Davies was later informed by a bereavement midwife that Evelyn had in fact been stillborn.
“I asked why she was referring to Evelyn as stillborn because I had been told Evelyn was alive and well at one point.
“She said ‘no, Evelyn was never alive’.
“I just assumed it was a communication issue. How could it be so fundamentally wrong? I’ll be honest, I am still trying to get to the bottom of that.”
Stephanie Bray, a midwife, told the inquest that baby Evelyn had not been responsive or breathing when she was delivered via C-section.
Coroner Chris Morris asked why she had then written “? showing some signs of life” in her notes before going back and changing them retrospectively some days later.
“I knew I had not written it in the right phrasing,” she told the inquest.
“I was hoping there would still be a heartbeat. I was hoping that resus would work.”
Ms Bray told the court she could not recall her exact words during her conversation with Major Davies but remembered saying baby Evelyn was ‘perfect meaning beautiful’.
Another of Ms Bray’s note which had been added in retrospect said that there had in fact been no signs of life.
An additional note, read out in court, said: “I believe this was a judgement error during a very stressful moment.”
Dr Mark Tattersall, a locum obstetrician on duty that night, said Mrs Davies was in ‘established labour’ when the decision was made to carry out the emergency C-section.
He said Evelyn had shown signs of suspected fetal bradycardia, a low heart rate, prior to delivery.
Professor Derek Tuffnell, an expert witness, told the coroner that compression to the umbilical cord caused by a membrane rupture could have caused Evelyn’s death.