Mother ‘sick with worry’ – inquest
Thursday 26th September 2013, 2:51PM BST.
A woman claims midwives treated her as an “anxious new mum” just hours before her newborn son collapsed and died in hospital.
Jared McDowall died at St Michael’s Hospital in Bristol on January 17 last year, two days after he was born by emergency caesarean section.
Avon Coroner’s Court heard his mother, Natasha, complained to hospital staff that her son was reluctant to feed and crying unusually.
Mrs McDowall, of Longwell Green, Bristol, said she was “sick with worry” over her son’s condition, but midwives simply dismissed her concerns as “paranoia”.
Just hours later, Mrs McDowall discovered her son, who weighed six pounds, floppy and lifeless in his cot.
Resuscitation attempts were unsuccessful and he was pronounced dead at 2.45am.
An inquest into Jared’s death heard a root cause analysis investigation (RCA) found four failures in his care, including failures to recognise poor feeding and unusual crying.
The hearing was told it was not possible to ascertain an exact cause of death, but Jared could have suffered from hypoglycaemia or low blood sugar, which may have triggered a collapse.
Avon Coroner Maria Voisin, who reached a narrative conclusion, is writing a report referencing ways to improve care at St Michael’s Hospital raised during the inquest.
“It is of note that the recorded observations were generally normal and staff did not have concerns about Jared’s progress,” she said.
“The parents did have concerns about his feeding and his crying and raised these with staff.
“The staff said his level of feeding was typical for normal babies and not of concern to them.
“In relation to his crying, they did not believe it caused any concern and were reassured when his observations came back as normal.”
Ms Voisin said she considered reaching a conclusion of neglect but heard no evidence of “gross failures” in Jared’s care by hospital staff.
She will now write a report to the hospital following comments by Dr David Harding, who made a number of recommendations to the inquest.
These included a graph showing birth weight and gestation, better synthesis between doctors and midwives and education packs for hypoglycaemia.
The inquest was told Jared was born weighing 2.7kg – 200g under the “low birth weight” of 2.5kg – by caesarean section at St Michael’s Hospital at 2.57am on January 15 2012.
He appeared to be doing well for the first 24 hours, but the following morning, Mrs McDowall noticed he was crying in a “jerky way” and reluctant to feed.
Mrs McDowall told the inquest she reported her concerns to midwife Natasha Bridge but was made to feel like an “anxious new mum” and reassured that her son was fine.
“I was sick with worry and felt I was being treated as a paranoid mother,” she said.
“At the time I felt I was being brushed off.”
Both Jared and Mrs McDowall were examined through the day but all observations returned as normal, with a second midwife also reassuring the family.
But in the early hours of the following morning, Mrs McDowall discovered Jared “floppy and lifeless” in his cot and rushed him to the midwife station for help.
“I repeated that he was ill all day and none of them had listened to me,” she said.
“The alarm sounded and a lot of medical staff came rushing to Jared’s aid.”
Resuscitation efforts did not succeed and Jared was pronounced dead at 2.45am.
Pathologist Dr Craig Platt said post-mortem tests showed Jared had high insulin levels but could not ascertain his glucose levels before resuscitation, meaning it was impossible to say whether he was hypoglycaemic.
He said the cause of death was “unexpected death of a neonate” but that Jared’s raised insulin levels, low birth weight, a pulmonary haemorrhage and anisonucleosis in his pancreas – which could suggest a problem regulating insulin levels – should also be recorded.
Mrs McDowall told the inquest: “I feel completely let down by the medical professionals at St Michael’s Hospital, particularly the midwifery team who failed to listen to my concerns.”
Midwife Natasha Bridge, who qualified six months earlier, said there were “no warning triggers” to refer Jared to a different ward or care team.
Experienced colleagues agreed with her observations and said Jared appeared healthy, with his feeding chart similar to other newborns.
But Jared had four feeds in a 24 hour period – one breast feed and three 10ml servings of formula – two fewer than recommended, the inquest was told.
Staff also considered his cry to be “unusual” but not “abnormal”, which would have been noted on medical charts.
Sarah Windfeld, head of midwifery at the University Hospitals Bristol NHS Foundation Trust, said charts now featured “unusual crying” as a result of Jared’s death.
Observations had also been increased, there was more supervision, extra training and support had been offered to staff and clearer ways to escalate concerns introduced, she added.
Speaking after the inquest, Jared’s parents Natasha, 37, who works in HR and Shaun, 43, an IT consultant, said they had suffered with depression after his death.
Mrs McDowall said: “We were absolutely disgusted at the care Jared and I were given and it has been very hard to relive the events during the inquest.
“Shaun and I knew something was seriously wrong with Jared and I was becoming more and more concerned because he wouldn’t feed, but the midwives made me feel like I was overreacting and that I was wasting their time.
“Jared was our first baby and we were so excited to bring him back to our family home but we never got chance to do this. His death still affects us every day and I’m not sure we’ll ever come to terms with it.
“To be honest what happened made us lose all faith in maternity services and we were terrified the same thing would happen again if I became pregnant.
“We just hope that Jared’s death was not in vain and that improvements are made in observational charts and training to ensure no other family has to go through the same ordeal.
“Nothing can bring Jared back but seeing improvements in maternity services might help us to begin the process of accepting what happened.”
Mr and Mrs McDowall have instructed medical law experts at Irwin Mitchell to investigate Jared’s death.
Julie Lewis, a partner at Irwin Mitchell’s Bristol office, who represents the family, said: “W e will now continue to work on behalf of Natasha and Shaun in liaising with the Trust to secure an admission of responsibility which we hope will help them to begin to come to terms with what happened and begin to rebuild their lives.”