The parents of a baby boy who died due to failures at Bolton Royal Hospital say they want his story to be told to stop the same mistakes from happening again for Baby Loss Awareness Week.

Aimée Whelan and Simone Rizzari, mother and father to baby Alfie, were left devastated by his death, which Bolton NHS Foundation Trust has now admitted would have been prevented if the correct procedures had been followed by midwives.

Baby Loss Awareness Week began on 9 October and culminates in a global wave of light on 15 October in memory of babies who have died.

Aimée, 23, who lives in Radcliffe, Greater Manchester, with Simone, commented: “The trust made a series of errors throughout our pregnancy, but in particular during the labour. The number of mistakes made that fell outside the lines of local and national guidance is tragic. If rules had been followed this horrendous ordeal would have been avoided. It’s hard to put into words how much this has opened our eyes to the problems that exist in maternity services as we were completely naïve before. It never even entered our heads that oversights so basic could happen. We want to make other parents aware so that they can question things more and know that these risks exist and hopefully make sure no one else suffers as we have.

“The NHS really needs to look at the processes it uses when managing a labour as I continually told to take paracetamol and have a bath, despite me being exhausted and in need of proper attention. This caused me a huge amount of stress and I would never want anyone to go through that. Within two weeks of Alfie’s death we were told the trust had already done a rapid review and were implementing immediate actions but a baby shouldn’t have to die for this to happen. I don’t want Alfie’s death to be in vain but I also want justice for him.”

Lucy Mellor, a specialist medical negligence solicitor at law firm JMW who is representing Aimée and Simone, said: “This is an extremely tragic case. Alfie should, quite simply, never have died. There were a number of mistakes which occurred throughout Aimée’s pregnancy and labour. Despite multiple opportunities to put things right, nobody took the steps to do so.

“Decisions about Aimée’s care should not have been placed with the midwifery team in the first place. If she had been placed on the correct pathway then she would have received care from an obstetrician, and a plan would have been put in place to ensure Alfie’s safe delivery. When Aimée did eventually go into labour, the care that she needed simply wasn’t there, and Alfie paid the ultimate price. Cases involving the avoidable death of a baby during birth often stem from basic failures, and this is another appalling example of that.”

Failures occurred throughout Aimée’s pregnancy and started when she was incorrectly categorised as low-risk. This led to Alfie’s birth being booked at standalone midwife-led birth centre Ingleside. Aimée was advised this was appropriate as she did not need obstetrician led care. She was also told that if she gave birth at Bolton Hospital then Simone would not be allowed to be with her due to Covid-19 restrictions, whereas at Ingleside he would be allowed.

Due to Aimée having a low BMI of 17.4 she should have been referred for ongoing review by obstetricians and a hospital birth should have been planned. Throughout her pregnancy midwives correctly recorded her BMI, however a referral was never made. The hospital trust has admitted that if this had been done, Alfie and Aimée would have received the correct treatment and he would have been born alive.

When Aimée’s labour started late in the evening on 5 January 2021 at 39 + 5 weeks, she faced further poor care. Midwives failed to ask her to attend Ingleside even though she had called on three separate occasions and was unsure whether Alfie was moving.

When midwives did agree to see Aimée at Ingleside, they failed to carry out an adequate assessment and recognise that, whilst she was in active labour, she was not progressing as expected and so something was likely wrong. Aimée, who at this point was 3-4cm dilated,  was told there was a four hour limit on how long she could stay at Ingleside but if she went home and took paracetamol this would allow her to get some sleep.

On countless occasions thereafter Aimée tried to telephone both the maternity triage unit and Ingleside to ask for help. Her calls largely went unanswered. When she did manage to make contact, her calls were not logged effectively. The trust had a dedicated computer system specifically designed to make sure that midwives working at both Ingleside and the maternity triage unit had access to the same information. Instead of using the system, midwives recorded Aimée’s calls on paper and then failed to file them correctly. This made it more difficult to recognise that all was not well with Aimée’s labour.

Just before 7pm on 7th January, Aimée was able to get through to the maternity triage unit on her 17th attempt and said that Simone had been unable to hear Alfie’s heartbeat when putting his head to her abdomen. Aimée was advised to come in to Bolton Hospital, but tragically midwives were unable to find Alfie’s heartbeat and gave the devastating news that he had died.

An investigation was launched by the Healthcare Safety Investigation Branch, which highlighted a large number of issues with the care that Aimée and Alfie received, and made recommendations for how care can be improved for other babies.

 

Ends

Notes to editors:

Admission of liability available on request.

Healthcare Safety Investigation Branch report available on request.

 

For more information or to arrange an interview, please contact Kelly Hindle or Samantha Meakin on the details below:

 

Kelly Hindle

 

M: 07921 388 584

 

E. Kelly.hindle@jmw.co.uk

 

Samantha Meakin

 

D: 0161 828 1981

 

E: Samantha.meakin@jmw.co.uk

 

Note to Editors

JMW Solicitors LLP is a leading Manchester law firm and offers a broad range of legal services to both commercial and private clients.

JMW’s Clinical Negligence team is headed up by leading clinical negligence lawyer, Eddie Jones.

http://www.jmw.co.uk/services-for-you/clinical-negligence/

 

 

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