Worthing Hospital’s maternity unit's missed opportunities lead to another baby death
Esme Vowels Lovett, the first baby of Chloe and Toby Lovett was born at Worthing Hospital (part of University Hospitals Sussex NHS Foundation Trust) on 18 February 2022, but her heart was no longer beating.
For seven years Chloe and Toby Lovett tried to conceive and in 2021 they finally received the wonderful news that they were expecting a child, Esme. It came after six miscarriages and the mental and physical anguish that goes along with it. Following a second round of IVF, they received the news that they were longing for.
However, from around 33 weeks, Chloe knew something was seriously wrong. She was experiencing considerable pain yet, when she voiced her concerns to the Trust, her cries were dismissed, or ignored.
Repeated missed opportunities to intervene
Despite Chloe’s many attempts to get maternity staff at Worthing Hospital to listen to her concerns, they went unheard even though hers was supposed to be classified as a high-risk pregnancy.
An internal investigation at the hospital found at least six missed opportunities to have intervened, with additional areas of concern surrounding Chloe’s care identified and six recommendations for improvement of standards at the Trust.
It was confirmed that Chloe had had a placental abruption, which all of her symptoms had alluded to. It was also discovered that she had polyhydramnios (too much amniotic fluid) that had gone undiagnosed – a condition which can result in a ten-times greater risk of stillbirth.
At 33 weeks, Chloe began a series of terrifying hospital trips and triage calls. It was at this point she visited Worthing Hospital with contractions and a lost mucus plug and was told a positive foetal fibronectin swap confirmed a high potential of going into labour.
However, after a few days, she left the ward with no follow-up or plan in place, other than to be given steroid injections to help the baby’s lungs and told about the neonatal intensive care unit (NICU).
Multiple pleas for help
Throughout the process Chloe never felt listened to or that any of her concerns were taken seriously. She said she was always made to feel a burden and that she was “gaslighted by every medical professional” she saw.
In the final weeks of her pregnancy, Chloe visited the hospital several times also making multiple calls to telephone triage suffering from ongoing stabbing pains that often left her unable to move. Each time she went into hospital, she was sent home having been assured there was nothing to worry about.
On one occasion, she was discharged with codeine to manage the agonising pain she was experiencing, despite her pleas to be induced after expressing how something felt wrong. Less than two weeks later, she sought help again for the same symptoms from the midwives at the Trust, only to be instructed to contact her GP for another prescription for painkillers.
In the final call to midwives before losing Esme, made a few days since the last, Chloe reported yet again the stabbing pains which had gone on for weeks were now accompanied by bleeding. She spent over 12 minutes explaining the pain through tears, following weeks of being bed-bound.
Chloe recalls: “I was told to go out and live my life. More specifically, to go to Waitrose. That is a phrase that will forever live with me.”
Despite her weeks of pleading to be properly assessed and taken seriously, Chloe and Toby’s worst fears came true at 38 weeks when it was confirmed that Esme had died. She was delivered by caesarean two days later.
Chloe has since been diagnosed with PTSD, suffering from severe panic attacks and flashbacks as a result of the ordeal. The couple both describe utter devastation at their loss.
Obstetric review should have taken place
Worthing Hospital’s own investigation found that there were missed opportunities to provide assessment and/or adequately monitor Chloe and her baby during pregnancy in view of her medical history.
It found that when Chloe called triage at 37 weeks, there was a missed opportunity for an obstetric review, and the plan made by the midwife for Chloe to contact her GP for pain relief and to ask her community midwife to arrange a consultant appointment was not appropriate.
Chloe had reported ongoing pain which should have been assessed by the obstetric team in a timely manner.
Sadly, the fact that Esme is classified as a stillbirth also means that an inquest into her death will not be held.
Chloe and Toby are now joining with other families in calling for a public inquiry into maternity standards at University Hospitals Sussex NHS Foundation Trust.
The current state of maternity care and birth trauma across England
England is in the midst of a crisis in maternity care, which is leading to more cases of birth trauma. This comes after a parliamentary inquiry into birthing trauma heard testimonies from more than 1,300 women and other stakeholders about giving birth, finding what it called a ‘postcode lottery’ for maternity care. The hearing calls for a national plan to improve birth centres.
Not only this, but maternity wards are continually falling in CQC rating standards. In February this year Worthing Hospital was downgraded to ‘requires improvement’ for safety and Chloe, along with a group of other bereaved parents, are calling for an independent review of the Trust.
The public are repeatedly hearing of similar stories of tragic deaths and brain injuries, for both mothers and babies, in wards around the country. It was widely reported at the end of 2023 that CQC records showed it deemed two-thirds (67%) of wards not to be safe enough, up from 55% last autumn, according to a BBC analysis.
“Chloe and Toby’s story is as tragic as it is frustrating. If Chloe was properly listened to by midwives and doctors during her pregnancy, there is a high chance Esme would be here today. This has become an all-too familiar story of mothers’ concerns not being heeded or acted upon by staff at Worthing Hospital.
We are supporting a number of families whose babies have been harmed or died as a result of failures at this Trust and we are seeing the same errors and poor standards of care being repeated.
We have serious concerns over the safety of the Trust’s maternity services, as was recently highlighted by Robyn Davis’ heartbreaking experience. Chloe’s call for an independent review is a sadly necessary one as the regularities of these experiences is and should be alarming to everyone.”
Laura Cook, birth injury solicitor representing Chloe and Toby Lovett
