A heartbroken mum was forced to deliver her stillborn baby after staff failed to notice a drop in heart rate because a monitoring machine was set to silent after suffering a paper jam.
Bethany Sowerby was 38 weeks pregnant when she rushed to The James Cook University Hospital in Middlesbrough after becoming worried about her unborn baby's movements. Staff started electronic monitoring of the baby's heart rate while they attended to other patients but around 30 minutes later Bethany noticed the machine had suffered a paper jam.
Medics struggled to find a heart rate and Bethany, 32, was transferred to the delivery suite before being told shortly afterwards her baby Hattie had died on May 16, 2023.
Investigation findings
An independent investigation has now found the heart rate monitoring machine's alarm had been triggered at the time of the paper-jam, but the settings had been switched to silent. The Healthcare Safety Investigation Branch (HSIB) said a re-print following the paper jam found Hattie's heart rate monitoring to be pathological but this was not recognised until after she died.
The HSIB report said failing to recognise the dangerous reading showing Hattie was in distress was likely to have impacted on the tragic outcome.
Bethany has since been diagnosed with post-traumatic stress disorder and continues to undergo therapy and take medication to cope with the loss of her daughter.
Family's grief
Bethany, of Redcar, North Yorks, said: "Our little Hattie would have turned three this spring and we'd have celebrated so many milestones by now, her first birthday, first words and first steps. But the reality is that I never got to take our daughter home from hospital. I carried her for nine months and we couldn't wait to meet her and introduce her to her sisters."
She added: "It was supposed to be one of the happiest days of my life, just like it had been with my other children, but it became the most traumatic thing I've ever experienced. Holding her for the first time also became the last time. She was so cold, I'll never forget what I felt in that moment. It broke me."
"When I came home after she passed, I couldn't bear to look at anything. The presents people had bought her, the clothes she was meant to wear and the room we'd decorated for her. Matthew and my children keep me going. I want to be the best mum I can be for my kids but there are days when the weight of losing Hattie feels overwhelming. Living with that grief while trying to be present for my family is something I struggle with every day."
Events leading to the tragedy
Bethany had repeatedly sought medical advice during her pregnancy whenever she became concerned about reduced movements. Plans had already been made to induce labour at 39 weeks because of recurring concerns.
On the night of May 15, 2023, Bethany attended the hospital's maternity triage unit after another episode of reduced movements. After an initial assessment found the baby's heartbeat to be normal, she was connected to a CTG monitor, which records a baby's heart rate and wellbeing.
A midwife then left to care for other patients. Around half an hour later, Bethany noticed the machine had suffered a paper jam and did not appear to be recording properly. She alerted staff, but when the monitor was checked Hattie's heart rate was found to be below the normal range.
Several midwives and a doctor rushed to help, but were unable to locate the baby's heartbeat. An ultrasound scan later revealed Hattie's heart rate had dramatically slowed and she needed to be delivered immediately by emergency C-section. Moments later, a second scan confirmed the little girl's heart had stopped beating.
Hattie was pronounced dead at 9.43pm. A post-mortem later found she had been deprived of oxygen before her death. Bethany, who has three children, Ella, 12, Olivia, nine, and Oakley, two, with partner Matthew Sowerby, 33, delivered Hattie the following morning.
Search for answers
Bethany is using Baby Loss Awareness Week to speak about the impact of Hattie's death on her family and their search for answers. Katy Daws, specialist medical negligence lawyer at Irwin Mitchell representing Bethany, said: "Bethany's maternity experience was extremely traumatic and the loss of Hattie continues to have a profound impact on her life. Both her and Matthew are still struggling to come to terms with their heartbreaking loss at what should have been a time of celebration."
"Our priority is now ensuring Bethany receives the support and specialist treatment she needs. In the meantime, the findings of the investigation report are deeply concerning and identify a number of issues. It's vital that lessons are learned to improve maternity safety for other families."
Baby Loss Awareness Week runs every year from 9 - 15 October. A spokesperson for South Tees Hospitals NHS Foundation Trust said: "The trust wishes to extend its sincere condolences to Bethany and her family for the loss of Hattie. The matter is in the hands of the parties' lawyers, and the trust is therefore unable to comment further at this time."
