In light of the recent article in the Citizen, we have decided to break our silence with the truth about what happened to our son George and the issues at Milton Keynes Hospital Midwifery Unit.
We, and unfortunately many other families, have been through an ordeal. For us this began in December 2013 when our beautiful baby boy George sadly passed away after only 36 hours of his short life. We believed this to be of natural causes and had accepted that nature took its course. However, 6 months later we found out about various mistakes that had been made during our labour. Only in July this year have we finally come to the end of various meetings, investigations and finally an official coroner’s inquest into George’s death. We feel we must now go public with our story as we have all the facts and details and are able to write from an informed, calm state of mind. We want to ensure that we can get our message across in the way we want which is why we have remained silent until now.
Firstly, prior to our labour George was a perfectly healthy baby with no issues whatsoever. After independent reviews by MK Hospital and two independent consultant paediatricians, we have found out that many mistakes were made during our labour, which while we cannot categorically state that George would have survived, we have had confirmed that it would have been very likely that he would have. This is obviously heart-breaking for us as parents and something we will live with for the rest of our lives wondering what should have been.
Without going into too much detail, the main issue with our care was a lack of foetal heart monitoring and failure to act appropriately upon two heart decelerations during the labour. As Kirsty had a water birth, the procedure was to listen in via a handheld Doppler. The guideline for this is every 15 minutes in the first stage of labour, reducing to every 5 minutes during the second stage. Throughout our labour the 15 minute period wasn’t consistently adhered to and never changed to 5 minute intervals in the second stage (the heart rate should have been recorded 29 times throughout the labour, but was in fact only recorded 16 times)
Various midwives at our inquest advised that in the event of a deceleration, the mother should be placed on a CTG monitor (which constantly reads the baby’s and mother’s heart rate and provides a live print out as the labour progresses). Unfortunately, the decision was made not to place Kirsty on a CTG monitor after either of the decelerations as the heart rate recovered. However, it has since been found out that this is not the protocol and this shouldn’t have happened. If Kirsty had been placed on a CTG monitor, any further decelerations would have been picked up immediately and appropriate action could have been taken. For George to have been born in such a poor condition means that he may not have received oxygen for up to 20 minutes prior to his birth. A heartbeat was located only 10 minutes prior to George’s birth. However, an experts in their independent review has said this is almost 100% likely to have been Kirsty’s heart rate and not George’s. There were many other issues with our labour and mistakes made, however none quite so important or life-threatening as the heart monitoring situation.
Unfortunately our case is not isolated. While mistakes were made during our labour there is no sole responsibility for George’s death. A total of five babies have had investigations under very similar circumstances. We are also aware of another baby that sadly died in January this year, which means that still a year down the line it seems mistakes may still be being made. The most recent case hasn’t yet been to the official inquest so we cannot state whether the hospital were at fault here, but in other cases including ours the hospital has accepted liability and offered compensation as a result. An Action Plan has now been put in place to address the issues and improve standards.
While there have been mistakes made, these errors are not representative of all midwives in the hospital, many of whom we are sure practise and adhere to the correct standard. Having said that though, we believe there to be much larger departmental issues including on-going training and pre-emptive action, with many similarities amongst some of the cases meaning individual errors cannot be solely blamed and these larger issues need to be addressed as well – again some of which are included in the Action Plan.
Our aim now is not just to tell people what has happened, but to raise awareness to ensure that there is pressure on MK Hospital to fulfil their promises on a long-term basis. Only a few years ago a similar series of baby deaths occurred at MK Hospital and plans were put in place to ensure it didn’t happen again, yet here we are just a few years down the line in the same situation. The Action Plan that addresses most of the issues will improve the department and ensure the safety of both mothers and babies. However, this needs to be permanent and not just until the dust has settled. In our case, it was such a basic mistake. Midwives are present at a labour to ensure that if things deviate from the norm, appropriate action is taken and this didn’t happen for us.
Nobody meant for this to happen, but it has happened and without sufficient education on the matter it is difficult for parents to look out for these things during their labour. We put our trust in the professionals in these situations and we believe that what they are doing is best for those we love. We urge people not to be scared to ask questions of your midwife or challenge decisions that you feel may be wrong. If you have a labour, request the option for a CTG monitor if you would like one for reassurance and ask the midwife for information regarding this. If you don’t have a CTG, please be aware that the heart rate should be checked EVERY 15 MINUTES, and in the second stage of labour EVERY 5 MINUTES. If there is ever a deceleration and you are not on a CTG monitor, YOU MUST BE PUT ON A CTG straight away.
Please share this message so that we can reach as many people in this city as possible to make them aware of the situation. We have confidence that MK Hospital will follow the Action Plan they have put in place. However, we need support to make sure this is followed through, ensuring the safety of future mums and babies.
Thank you for taking the time to read our message.
Jonathan and Kirsty Stansfield.
Jonathan, Kirsty and their family and friends have formed a fund-raising group and Facebook page called Team George to raise cash for the neonatal unit at John Radclliffe hospital, where staff battled to help baby George.
Already Team George has raised £80,000 to but life-saving equipment for the unit.