Three years ago we were let down by systems and procedures and policies within the NHS. Sepsis wasn’t very well known about then, not like it is nowadays. There is a massive campaign for the public to be aware of the signs and symptoms. Sadly we are one of those families that will forever live with the destroying affects of Sepsis.
In your short time Charlie you were seen by three midwives. Sadly these individuals didn’t have the training to identify you were poorly, dying before our eyes.
Midwife 1 assessed me at hospital, allowed me to go home, when in hindsight I should have been kept in hospital, you would have been born in hospital, and all the signs of invasive strep A and Sepsis would have been spotted and treated, with the high chance you would be here tonight.
Midwife 2, we first met her two days before you were due, she gave excellent advice on if we felt it was a quick labour not to get in the car, it was unhygienic. We saw her again the morning you arrived, she came to the house after four paramedics, she stayed with us for a couple of hours. She felt you were a well baby, that I was well. She didn’t feel there was any need to go to hospital to be checked.
Midwife 3 we first spoke to just 6 hours after your birth, you wouldn’t feed, you weren’t stirring for feeds, you were sleeping a lot, you were making a funny noise. She said she would get to us as soon as she could. Five hours later she came. You still hadn’t fed, she noticed you were grunting, but still didn’t admit you.
Midwife 4 we met the next morning, you had barely fed, you slept, you grunted. She noticed you were poorly. You collapsed in my arms and she tried to bring you back.
All these people could have made a difference. The very least they could do was apologise, to learn and to never make the same mistake again.
We pushed for answers when you died, Me and Daddy spent so many hours researching the trusts policies, of other cases where babies were born down the toilet, of neonatal infections. We were persistent with passing all the information we had found, all the policies that hadn’t been followed onto the coroner. She realised there was no way she could hold an inquest of a couple of hours, that this was much bigger than just a sad death. She got professionals from Bristol, London and Birmingham.
At the inquest was the first time me and Daddy faced some of the people involved. There were 13 witnesses plus reports from others.
We were asked by the Trust if we would meet the four midwives involved, away from the camera and press. We agreed. We felt it would be rude not to, and at the end of the day they didn’t intend for you to die, did they?
Even today Charlie I find it hard to accept that they learnt lessons from your life and death. Midwife 1 apologised and said she wished she hadn’t sent me home. Midwife 2, didn’t apologise, just asked how we all were. Midwife 3 was clearly upset and had learnt from it all, she apologised. And midwife 4, well she was the one who had to resuscitate you, she was so sorry.
They all took the stand, they all gave their evidence. They got questioned by the coroner and the professionals as well as our legal team. Three of them were sorry, sadly there was one midwife who remained defensive, she failed to apologise, she failed to accept there was things she could’ve done differently. She remained defensive throughout.
Following various meetings to improve services for other families, we have learnt midwife 3 had taken time off, due to the stress and press coverage she received. She has recently gone back to work but no longer does newborn baby checks, it’s affected her confidence. Midwife 4 continued to work, but was woken for a long time after with nightmares, she could feel your lips on hers as she resuscitated you.
But midwife 2 continued to work, failed to acknowledge us whenever our paths crossed. First I was sad that she couldn’t even speak to us but this slowly bubbled to anger. A boiling bubbling anger that lead me to ask questions about her practice, her learning from it all. We got told that sadly she was diagnosed and it was terminal, that she was off sick so the trust couldn’t even pass on the questions I had that I needed answers to, that only she could answer. I asked to be able to email, for them to pass it on, to explain that it was for closure for me.
I finally got access to some of her reflective learning, which took a lot of asking for. And as much as I told everyone “that’s ok, if that’s all I get I can accept it”, what I was still longing for, hoping for was that there would come a day where she would be able to have a meeting with me, to answer an email, to give me the answers I needed to move and most importantly to tell me “I’m sorry”.
At my recent counselling session I got told she had passed away. And what did I do. I burst out crying, uncontrollable crying that I couldn’t explain. When I could finally catch breath I was able to say ” well that’s it then, she’s never going to apologise”.
Everything I had hoped for had gone. Just two simple words.
A massive part of me is filled with anger and hate. She got away with it, she didn’t apologise and she didn’t learn. And at the moment this is how I feel. There is a small part of me that does feel sorry for her family, for her young grandchildren. But there’s a bigger part of me with a longing that will never come.
You changed our lives Charlie, and I know you have made changes within the NHS, that there are professionals that think of you on your anniversary.
Some people have said maybe she couldn’t apologise because it would have meant her accepting she could have made a difference, that now she is in heaven she has found you and apologised to you. And yes that is a nice thought. However she beat me to it. She got to see you again before I did. Somehow I have to find peace with this feeling of longing, and right now I’m not sure how.
I truly don’t know how to find peace with this.
Night night baby boy
Love mummy xxxxxxx