Mum fears 'admin error' contributed to son's death

A mum fears an "administrative error" when she moved home meant she went without antenatal care for 10 weeks, which she believes led to the stillbirth of her son.

Kelly Whitehead had hoped her second pregnancy would be the time "everything went right" after the premature birth of her twins.

The 37-year-old said she informed staff at Queen's Medical Centre, Nottingham, that she was moving and her phone number would need updating, but she believes this was not done and she went without care between 31 and 41 weeks. Her son, Christopher, was stillborn in April 2019.

Nottingham University Hospitals NHS Trust (NUH) said there were missed opportunities in the case which it "deeply regrets".

Whitehead who moved to Clifton from Hyson Green, said she initially blamed herself for not fighting harder to be seen during the 10-week period.

She added: "I was mostly attempting to call community midwife services in my new area advising that I had moved and that I wasn't able to attend the old GP.

"And because records hadn't been sent through I was being told to communicate back to my old community midwife services.

"At the time with my twins' health, and my health, I just felt like I was beating my head against a brick wall with it and I just felt like I was running around in circles with it and being passed between two areas."

Whitehead's twins, who are now eight, were born about six weeks premature and each spent weeks in the neonatal intensive care unit at QMC.

Whitehead said that during her pregnancy with Christopher the twins were still "extremely unwell", meaning she was "struggling to leave the house" to make appointments.

She added that after informing hospital staff she would need her details to be updated, contact "seemed to evaporate".

"When I tried to access support I was either told to wait or passed between the community service between the new area I'm living in and the old area I was registered with.

"So from that point on really I had no care."

At 40 weeks, she contacted QMC asking to be seen, raising concerns that she had not been seen since her appointment at 31 weeks.

She was also worried about cramping and that she may be missing the signs of labour.

She was told the cramping could be Braxton Hicks and said she was told to "wait until next week and if you haven't [gone into labour] we will induce you".

However, she contacted the hospital a week later and was brought in for a scan, where midwives were unable to find a heartbeat.

Whitehead said her placenta "failed" in the days leading up to the stillbirth and enough oxygen wasn't getting through to Christopher.

She added: "I think I immediately went into shock when they told me they couldn't find his heartbeat.

"It's a trauma I don't think anybody knows unless they've been through it.

"Not to say that grief isn't difficult for everybody, but it is a specific kind of grief when you lose a baby that you never got the chance to meet.

"It's just the promise of life that didn't follow through.

"I do believe had I been seen the week prior he would have been okay.

"I do believe it was an administrative error, whether by system or human error I don't know.

"Had those details been updated at the right time I would have been seen more consistently and I do believe that my son would be alive today."

Tracy Pilcher, chief nurse at NUH, said there were missed opportunities in Whitehead's case.

Pilcher added: "We would like to extend our sincere condolences to Ms Whitehead on the loss of her son, Christopher.

"Following a review of the care provided during Christopher's birth in April 2019, it was identified that opportunities were missed for community and hospital maternity teams to effectively share information regarding missed appointments.

"We deeply regret that these opportunities were not taken.

"As part of the case review, several areas for learning were highlighted, including the need to strengthen processes, guidelines and procedures relating to non-attendance at appointments.

"We continue to regularly review and improve our procedures and provide ongoing staff training in this area."

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