Kirkby couple campaigning to improve maternity safety after death of one-day-old son

Theo Bradley had to be resuscitated after he was delivered by category one caesarean at King’s Mill Hospital in Sutton.

Mum Amelia Bradley was admitted to the hospital around an hour earlier concerned she was bleeding.

An inquest heard that local hospital guidelines stated she should have been triaged to assess her and baby’s condition within 15 minutes of arrival. However, it was nearly 40 minutes before she and Theo were assessed, despite being the only patient in triage. During the wait, Amelia’s partner Luke Sherwood and mum, Tammy, shouted several times for staff to assess her, the court heard.

During their wait Amelia and Luke, both 26, heard maternity staff chatting, including one who said: “I can’t believe how many Haribo’s I’ve had tonight,” the hearing was told.

When they were assessed, Theo was found to have a slow heartrate. A decision was made to deliver him via category one caesarean – where there is an immediate threat to the life of mum or baby.

After he was born, resuscitation equipment on the unit was found to be missing.

Theo was transferred to a specialist neonatal unit for treatment. However, his condition continued to deteriorate. He died the following day in his parents’ arms surrounded by his family.

A post-mortem examination found he died after suffering a serious brain injury caused by a lack of oxygen.

Following Theo’s death Amelia and Luke, of Kirkby, instructed expert medical negligence lawyers at Irwin Mitchell to investigate and secure answers at an inquest.

The couple have now joined their legal team in calling for lessons to be learned.

It comes after an inquest at Nottingham Coroner’s Court reached a narrative conclusion.

Assistant coroner, Elizabeth Didcock, found neglect contributed to Theo’s death and she found that if Theo had been delivered earlier, on balance, he would have survived.

A Healthcare Safety Investigation Branch (HSIB) report also found issues in the family’s care, including training for maternity triage staff was not mandatory. This affected the understanding of the roles and responsibilities within the area and the importance of a “prompt full triage assessment was not prioritised.”

Laura Robinson, the specialist medical negligence lawyer at Irwin Mitchell representing the family, said after the hearing: “It’s less than a year since Theo died, and losing him so suddenly and in such traumatic circumstances continues to have a profound effect on Amelia and Luke.

“The pain and grief they feel has been made worse by the questions they had around the events that unfolded in the lead up to their baby boy’s death.

“While nothing will ever make up for what Amelia and Luke are going through, we’re pleased to have at least been able to provide them with some of the answers they deserve.

“Sadly, however, the inquest has identified issues in the care prior to Theo’s death, especially around communication, training among maternity staff, and staff culture.

“Every second counts when delivering a baby in distress. It’s now vital that lessons are learned to help improve maternity safety and prevent other mums and dads from suffering the way Amelia and Luke have.

“We’ll continue to support them at this difficult time.”

Amelia and Luke attended King’s Mill Hospital at around 9.30pm on September, 13, 2023, after her contractions started. They waited for over an hour to be seen before Amelia was given pain relief and underwent a sweep. She was allowed home within approximately 15 minutes at around 11.30pm, the inquest was told.

Just after midnight Amelia started passing blood and experiencing unbearable pain. After Luke called the hospital to explain Amelia’s symptoms, they were advised to return. The couple and Amelia’s mum Tammy, 46, arrived at around 1am on September 14.

The inquest was told that when they arrived that Amelia was in a wheelchair due to the amount of pain that she was in. They told hospital staff again about the bleeding and were directed to go into a triage room.

Around 15 minutes later Amelia had observations taken by a health care support worker. The family attempted to show the health care support worker evidence of the bleeding, but were advised that a midwife would be in shortly.

The inquest heard that numerous midwives were sat around the desk. When it was recognised that Amelia had not been assessed, one of the midwives admitted to making a comment about a colleague, a labour ward midwife, earning more money than her due to working a bank shift.

Amelia was finally assessed at 1.42am. A call for a specialist obstetrics review was made. Theo was delivered at 2.02am.

The HSIB report presented to the inquest found there was no allocated lead in the maternity triage department, so nobody had responsibility for assigning roles and managing workload.

The inquest heard that despite the triage roles being allocated on the Trust’s roster system, both present triage midwives did not take responsibility on who would see Amelia upon her return to hospital, causing unnecessary delays in the rapid assessment.

Sherwood Forest Hospitals NHS Foundation Trust, which runs King’s Mill Hospital, had recently introduced a new triage system to prioritise care for pregnant women. However, the session was not mandatory for none ‘core’ triage staff and not all ‘core’ staff had attended the training session, the report said.

It also found during the call in which Amelia was advised to return to hospital further questioning around the extent of her bleeding could have been asked to establish whether she needed to be brought in by ambulance.

Evidence given by an obstetrician from the Trust at the inquest stated that Amelia’s presenting symptoms should have prompted an immediate assessment.

The 29-minute delay in Theo receiving resuscitation medicines and blood products may also have impacted Theo’s outcome, the report added.

The report made six safety recommendations including a maternity triage lead is allocated to ensure there is oversight of the area. All staff involved in maternity triage should undertake training to understands their own responsibilities and those of colleagues.

The Trust should also ensure when a mum calls the department with bleeding the “significance is identified” and if needed, an ambulance is called. It should also ensure emergency resuscitation equipment is available to all staff.

An obstetrician from the Trust advised the coroner during evidence that if Amelia had been assessed promptly, it was more likely than not that Theo would have survived.

Amelia, who has applied to start a midwifery degree starting in September said after the inquest: “Following Theo’s death, Luke and I discussed how we wouldn’t ever want another family to have to go through what we’re going through.

“I want to honour Theo’s name and to use this awful experience to be an advocate for women and help deliver the best care and support that women should expect to receive.

“To lose Theo so soon after he came into the world is something we’ll never get over. We’d been looking forward to becoming a family and to have that ripped away from us in such a cruel way was nothing short of traumatic.

“To this day, I still wake up and hope it’s all been a nightmare and then it hits me and I’m completely floored by the grief. Knowing that our baby boy will never even celebrate his first birthday is so difficult to come to terms with.

“Hearing everything again at the inquest has been unbearable, but we’re grateful to have some answers now.

“We would do anything to bring Theo back, but we know that’s not possible. All we can hope for now is that no other families have to go through the heartbreak we have. I wouldn’t wish it on anyone.”

Phil Bolton, chief nurse at Sherwood Forest Hospitals, said: “I would like to take this opportunity to reiterate our unreserved apology to the family of baby Theo at what we know has been and continues to be an incredibly difficult time for them.

“Only the individuals involved that night truly know why Theo and his family did not receive the care they needed and deserved, and I am clear that we have failed to live up to the high standards of care that our communities are right to expect from their local hospitals.

“We have gone through a thorough HR process following Theo’s death to take decisive action and appropriate actions have been taken.

“We will take the Coroner’s findings on board and will continue working with Theo’s family to do all we can to prevent this from happening again.