The death of a baby is devastating for any family – but Sacha Parsons and Andy Cassidy are living with the added grief that a maternity unit’s errors robbed them of their longed-for first child.
The couple, from Somerset, want to tell what happened to their daughter, Anais, to help parents understand the risks some babies face, and ensure that such a tragedy never happens again, anywhere.
Anais died in the womb just one day after her predicted birth date last May. She was small, and not growing as she should have been.
Midwives at Paulton Memorial Hospital, near Radstock, had noted that she was small in the later stages of Sacha’s pregnancy, but errors were made in the way her growth was recorded and in assessing its significance.
Wiltshire Primary Care Trust has admitted that Anais’ birth should have been induced before the day she died. In the words of the NHS Litigation Authority, if it had been, ‘on the balance of probabilities, Anais would have been born alive.’
The trust has admitted a breach of duty – ‘That the standard of antenatal care was not in accordance with a reasonable, logical and responsible body of practicing obstetricians or midwives.’
Just 12 days after Anais died, maternity and some other services run by the trust were taken over by Great Western Hospitals NHS Foundation Trust.
It acted quickly on issues raised in an initial investigation. Training in measuring, documenting and plotting crucial growth details took place and the investigation findings were shared with all maternity staff.
The knowledge that their daughter could have been saved was a crushing blow for the couple. Sacha, 39, a finance officer at Writhlington School, Radstock, and Andy, 40, a self-employed electrician, had been trying for a baby for three years, and had suffered the misery of an early miscarriage in 2010.
They have reported three midwives to the National Midwifery Council, and are awaiting the settlement of a clinical negligence claim against Wiltshire Primary Care Trust, but what they want most of all is for professionals and parents to learn from the tragedy.
Here, Sacha tells the story of Anais, the beautiful baby who will never be forgotten.
“I am writing this for other people who might be in my position. It’s to tell them to ask for a second opinion if they think it is needed. I did not question what the midwives were telling me because they were the professionals and I thought they knew best.
“I found out that I was pregnant in September 2010 but we did not want to get too excited after what had happened earlier in the year.
“Everything progressed well and I felt so special to be carrying our baby around. We listened to the heartbeat at 16 weeks and at around 19 weeks I started feeling the tiny flutterings.
“All the antenatal checks went to plan and in early April we started buying nursery items and completely redecorated the spare bedroom.
“A midwife told me I was having a textbook pregnancy and I felt great right up to the end and even kept riding my horse until 34 weeks.
“At my 36-week check I was told that the baby was a bit small but not to worry, so I didn’t. After all, they are the trained professionals and wouldn’t jeopardise anything. At the 38-week check, I was told the same again, that the baby was still small and not to worry. A second midwife also confirmed this and said that a couple of weeks either way was OK. I remember her being very matter of fact.
“I had my final check-up on Thursday, May 19, 2011, in the afternoon, which was my due date. Again the midwife said the same, that the baby was small, but also said that she wouldn’t be doing her job properly if she didn’t refer me for a scan, which she did.
“These last few appointments, I had seen a different midwife every time.
“On the Friday I remember feeling some very small movements in bed in the morning, which was usual.
“At lunch time, I remember that for about 30 seconds I felt quite sick and had stomach ache. I just put this down to being due any minute. I now know that this was her way of telling me the exact time she had gone.
“All afternoon I didn’t feel any movements but didn’t over-worry at this point. By teatime I started worrying and phoned Paulton birthing unit. They told me to come up immediately for a heartbeat trace which I and Andy did. A trainee midwife started to try and find a heartbeat.
“She tried for about half an hour. Every so often she got mine and I thought all was ok. We were then told to go straight to Bath for a scan. There our worst fears were confirmed at about 8pm, when the midwives told us they were very sorry.
“I didn’t look at the screen. Our lives changed forever from this second onwards. I was then given a gel to induce me and we were left on our own for a while. Andy had to make the awful phone calls to our parents. They came immediately. I didn’t know what to feel or think and just laid on the bed with a blank mind. Even when family arrived and started crying, I didn’t. We were then taken to the bereavement room, which is like a self- contained flat.
“Andy had to go home to pick some things up as we had nothing with us. He came back at around 11pm. I got my pyjamas and went into the bathroom to change. It was at this point that it hit me as I could see my large bump in the mirror and knew that we wouldn’t be taking our baby home. I then started crying and screaming and Andy came in to comfort me.
“The next day my labour began and our baby arrived at 5.05pm, weighing five pounds seven ounces.
“Andy and I had hoped for a girl all along and we got our wish. She was absolutely beautiful and completely normal in every way. Andy cut the cord and asked me what I wanted to call her.
“I remember that Andy liked Anais so that’s what we called her. Anais just looked as though she was sleeping. All her family came in and were able to kiss and cuddle her. Even my nan, who was 88 at the time, came and she was so glad that she did.
"Anais knew more love in her short stay with us than some children know in a lifetime.
"Me, Andy and Anais were able to stay with each other until later that evening, when we had to hand her back to the nurse. She was dressed in a little outfit which my nan bought her and a blanket that either my nan or mum made for my nephews, years earlier. I fell asleep with her in my arms and Andy took some pictures on his phone. We just gazed at her all evening and wondered how we could have made something so beautiful and perfect.
"We bought a pretty little pink flowery dress and tights for Anais to be buried in, and as her mum I was able to dress her for the only time in her new clothes.
"We live in Chilcompton in Somerset and Anais is buried at Haycombe in the butterfly garden along with all other little babies.
"She was buried with a teddy matching one that we have, a penguin rattle that my mum bought for her at Weymouth a while ago, cards and teddies from her cousins and a lock of mine and Andy’s hair, as we have hers. I carry her hair in a locket which I will never remove, and we have a memory box which includes prints of her little feet and hands.
"The first few weeks after Anais’ birth passed with Andy, and I still in shock, but our families kept visiting and were a great source of strength.
"Exactly a month after we lost Anais, on June 20 last year, I went back to work. The first day was very hard but all my colleagues were great.
"The first Wednesday back, we had an appointment at Royal United Hospital, Bath, with the consultant obstetrician. I had so many questions for her as I believed it was something that I did.
"None of my questions was justified however, and in a nutshell, the consultant confirmed that Anais’ birth weight was tiny and rated very low in a growth chart that she had. She had stopped growing. The midwives at Paulton Memorial Hospital, where they measured her as small and told me not to worry about it, had played God with my baby’s life and our little girl paid the ultimate price – her life.
"We wanted justice for Anais and appointed a solicitor who specialised in this area of law, called Claire Stoneman. Luckily, our home insurance was prepared to cover the costs. Although we would have found the money somehow.
"Shortly after this we were visited by the head of the Paulton unit who had heard that we were not happy with their care. As soon as she sat down in our front room she put her hands up and said: “We got it wrong.”
"As well as neglecting to do anything about Anais lack of growth, they also omitted to fill in a growth graph which would have been a very obvious visual aid that something was seriously wrong.
"However, they are not in the realms of punishment so the midwifes concerned had extra training. How do you imagine that made us feel?
"I received ten counselling sessions through my GP. She was not a specialist grief counsellor but it was good to talk about my baby as by this time people had stopped talking about her and I didn’t like it. I wanted everyone in the world to know of her existence, albeit in heaven.
"At the beginning of March this year Claire rang to say that Wiltshire Primary Care Trust, which ran Paulton Memorial Hospital at the time I was under its care had admitted a breach of duty, that the midwives had been in the wrong. To hear it officially and then to read that if action had been taken our baby would be here was heart-breaking.
"As well as going through the financial settlement – which I feel is an absolute insult – I am reporting the midwives concerned to the National Midwifery Council and aim to let everyone know about our story through publicity so that parents-to-be are prepared, and to stop it happening ever again.
"One of the things that we asked for was that the growth graph which is in each pregnant woman’s maternity book should be in a more prominent position.
"We think this would help parents realise its significance. I was reassured by being told by midwives that Anais’ slow growth was nothing to worry about.
"I did not think there was any reason to challenge it.
"At one point I was told that “a couple of weeks either way” was nothing to worry about. In fact by the 40th week she was five weeks behind.
"It was only on the day Anais was due that a midwife said she would “not be doing her duty” if she did not arrange for a scan. But there was not time for it – Anais died the next day.
"Living without our baby is almost unbearable. I go to her room every morning and night, and sometimes in the day, and talk to her and kiss and hug her photo.
"My partner, Andy, has been incredibly supportive of me throughout and I don’t know what I would do without him. There was a big strain on our relationship at the beginning. However, now I feel that our relationship is much stronger and I appreciate him a lot more.
"As for those midwifes, I despise them. Their lack of care took our wonderful baby away from us forever. They may have taken away our one and only chance of having a baby.
"In March this year I was pleased to do a positive pregnancy test. This time we went to Royal United Hospital, Bath. I would never go to Paulton again. When I was meant to be eight weeks pregnant the fetus was only measuring six weeks and a scan confirmed that I had lost it.
"I had a similar experience before conceiving Anais.
"I long for the day when Andy and I have a live breathing baby to take home, but this is taking some time and may not even happen. We have our first appointment with a fertility clinic shortly. Another baby will bring us happiness again but it will never make up for losing Anais, nothing could ever do that."
THE NHS' RESPONSE
In April the chief executive of Wiltshire Primary Care Trust, Ed Macalister-Smith wrote an official letter to Sacha and her partner, Andy Cassidy, apologising for the failures in care.
Paulton Memorial Hospital is now run by a Great Western Hospitals NHS Foundation Trust. Helen Price, the trust’s associate medical director, Women and Children’s Services, said: “Our trust took responsibility for the maternity service at Paulton on June 1, 2011 after this very sad case took place in May 2011.”
Responsibility for the service at the time was under NHS Wiltshire which admitted liability in this case and are awaiting the outcome.
A statement said: “When we took responsibility for the management of the service we were quick to ensure that the issues raised through the initial investigation were addressed making improvements to training in measuring, documentation and plotting of Symphysis Fundal Height (SFH).
“Our supervisors of midwives have been involved in implementing these changes, their role is to give guidance and support to midwives and expectant mothers to ensure that the right care is provided, and they also ensure that midwives maintain their fitness to practice. We have shared the findings from the investigation with all of our maternity staff so that all staff are aware of the issues and are able to learn important lessons raised by this case.”