After her newborn daughter passed away, a grieving mother found herself in a distressing situation where she had to fight with hospital staff to obtain information regarding the cause of death. This came after an internal assessment commended the staff for their exceptional care.
Sarah Robinson, along with her partner Ryan Lock, experienced a typical pregnancy and had decided on a water delivery for their baby girl, Ida, at the Royal Lancaster Infirmary in November 2019.
But Ida’s heart rate plunged during delivery and the newborn was transferred to the Royal Preston Hospital where she died a week later.
During an inquest, Ms. Robinson expressed her dissatisfaction with the care she received. She mentioned being asked to exit the birthing pool without any sense of urgency and highlighted the midwives’ delay and lack of seriousness, even going as far as making jokes about the challenges of using new labour beds.
‘No one alerted Ryan or I to the fact that they couldn’t identify Ida’s heartbeat. Looking back, they didn’t appreciate the time they were losing,’ she said.
She told the inquest there had been a ‘real sense of obstruction’ from University Hospitals of Morecambe Bay NHS Foundation Trust to her attempts to find out what went wrong.
A report from the Healthcare Safety Investigation Branch (HSIB) identified a series of hospital failings in the handling of Ida’s birth, but the trust praised ‘outstanding’ aspects of its treatment when it delivered its own report two months later.
‘It was like night and day compared to the HSIB report,’ Ms Robinson told the hearing. ‘It was completely different.’
On Monday, Sarah Robinson said she and her partner, Ryan Lock, had experienced ‘a rollercoaster of emotions’ in a fight for answers and ‘justice’ since the birth of their daughter Ida (pictured)Â
Sarah Robison told a coroner how she was questioned by staff in the aftermath of the birth after a midwife noticed her placenta looked ‘gritty and fatty’
Ms Robinson told the coroner how she was questioned by staff in the aftermath of the birth after a midwife noticed her placenta looked ‘gritty and fatty’.
And she said she was asked repeatedly whether she smoked, despite being a lifelong non-smoker.
The couple say staff failed to inform them that Ida’s heart rate was high, or that it could later not be detected by midwives.Â
Following their daughter’s death, Ms Robinson said she and her partner were ‘desperate’ to speak to the hospital in a bid to find answers and a meeting was set up for late December 2019.
Ms Robinson said: ‘I was told ‘we don’t have anywhere to do this, is it OK to do this in the delivery suite?’
‘That shocked me, I thought ‘absolutely not’.’
Instead the meeting took place in an office on Ward 17 where women are cared for before and after birth, the inquest heard.
Ms Robinson said being around newborn babies at the time was ‘torture’ and ‘distressing’.
She said: ‘It seemed incredibly insensitive to our circumstances. We came away from that meeting thinking that Ida was in a very poorly condition when she was born.
‘It took a long time to get over that meeting, I thought it was something I had done.
‘The meeting didn’t provide any answers or explanations. We were provided with the medical notes. No-one took us through it, nothing to explain the notes.
Partner Ryan Lock is pictured reading aloud to baby Ida, who sadly died a week after her birth
Ida was the couple’s second child – the NHS trust has since admitted multiple failings in care
‘I had sorrow and anxiety which intensified for months, the only way I could describe myself was numb.
‘I fell into a vicious circle, constantly questioning as to whether I was the reason that my daughter had died, and what had I missed. I felt so guilty.
‘All of this was made more difficult by the lack of information from the trust which made it impossible for us to truly understand what had happened.’
It is the latest case to trouble the trust, which was the subject of a damning report in 2015 that found a ‘lethal mix’ of problems at another of its maternity units at Furness General Hospital that led to the unnecessary deaths of 11 babies and one mother between 2004 and 2013.
The Morecambe Bay investigation, chaired by Dr Bill Kirkup, uncovered a series of failures ‘at every level’ from the unit to those responsible for regulating and monitoring the trust.
He made more than 40 recommendations but after further scandals in Shrewsbury, East Kent and Nottingham, Dr Kirkup admitted earlier this year they had failed to ‘stop the recurring cycle of catastrophes’ in NHS maternity units.Â
Ida died on November 16, 2019, the hearing at County Hall in Preston was told.
Ms Robinson told the inquest it was ‘heartbreaking’ to receive the HSIB report in April 2020 which identified failings in Ida’s delivery.
She went on to issue a complaint against the health trust via an email in which she questioned whether alternative actions from the midwifery team could have prevented the death of her daughter.
In the email, she added: ‘It should not be a test of endurance for bewildered and grieving parents to work out what happen.’
In June 2020 the couple, from Morecambe, received the hospital’s root cause analysis (RCA) report of the issues with Ida’s delivery, the inquest heard.
‘We had a week to read what the trust had come up with as to how they had seen the incident,’ Ms Robinson told the inquest.
‘They said there were no care delivery issues whereas the HSIB report said there were many.’
In a meeting that followed she said the hospital acknowledged a number of failings in Ida’s delivery and care, she said, and were told that the RCA report would need to be rewritten.
Ida’s brother Ethan listens to her chest during her stay in hospital
Ms Robinson told the inquest: ‘I just questioned the integrity of it. Why was it not done right in the first place?’
The hearing was told that more than four years later the trust had accepted failings in a new ‘position statement’ issued last December.
Ms Robinson said: ‘Myself and Ryan want to ensure that lessons are learned and effective system changes are made so that history doesn’t have to repeat itself.
‘I hope that no other parents or families have to suffer in the way that we have.’
Giving evidence, Mr Lock said he was ‘concerned’ that the failings in hospital care were ‘endemic’ and he was of ‘the firm view’ that he and his partner would have had no insight into the events at the Royal Lancaster but for the involvement of the HSIB.
He said: ‘This has changed me as a person. It’s a sheer test of endurance that no parent should endure… it’s a fight for justice, in my eyes.’
The inquest continues.
