Parents shocked by scale of errors in baby tragedy

Tracy and Stuart Bray had suspected mistakes were made during the delivery of baby Tily at the Huddersfield Family Birth Centre on September 19 2009 but they were left deeply shocked by the scale of errors uncovered in an internal review of the case.

Mr Bray, 33, an air conditioning engineer, said they had wanted to use the centre so Tily could be born in Huddersfield.

“We are both from Huddersfield and we wanted that to be on the birth certificate,” he said.

His wife, 36, who is an accounts clerk, said she had no concerns during the pregnancy. At one stage they had been told the baby might be small for dates but this had been ruled out following checks by staff.

But the review found a doctor had failed to correctly assess concerns from a midwife that Tily’s growth had slowed, which would have alerted staff that the case was no longer low risk, further assessments were required and the delivery should be at Calderdale Royal Hospital in Halifax where specialist staff are available.

It found there was a lack of understanding of the use of height charts to calculate the growth of babies. An ultrasound scan should have been carried out but there were problems accessing scans in Huddersfield for midwives and they had to refer cases to doctors.

The review said Mrs Bray suffered blood loss in early labour. Midwives correctly decided to transfer her by ambulance to Halifax but then cancelled the move as they wrongly believed rapid progress was being made – in reality it was still nearly three hours until Tily was delivered.

The report said: “The investigators believe that transfer should have proceeded once the ambulance crew were on site. This would have enabled continuous foetal monitoring to take place to assess the wellbeing of the baby and delivery could have been managed appropriately according to the findings.”

It said “it cannot be stated that transfer to the consultant unit would have altered the outcome” but it would have led to better monitoring.

When Tily was delivered, she had a heartbeat but was not breathing and a crash call was made. But the inquiry found there was confusion over which specialist doctors to summon, while the on-call anaesthetist who took over the resuscitation had no neonatal training. Staff also did not know their way around the centre, leading to further delays.

Efforts to revive her were hampered by a lack of familiarity with equipment, while an oxygen mask did not fit properly. Suctioning was used to try to clear secretions from her mouth but the suction was inadequate.

The couple, who married four years ago, say they took legal action through personal injury specialists Irwin Mitchell after discovering the scale of problems.

They became parents again last March with the birth of baby James but because of their previous experience refused to use midwives through the pregnancy and instead received care through their GP. They also opted for delivery at Leeds General Infirmary, where Mrs Bray praised the quality of care.

“They’ve been smashing. They explained absolutely everything to us,” she said.

Her husband said he hoped major improvements had been made at the birth centre. “For the aftercare we should really go to Huddersfield but I really have no faith in them whatsoever,” he said. “There was always going to be a time when something went wrong. They weren’t prepared and we lost Tily.”

The Calderdale and Huddersfield NHS trust said: “As a result of the inquiry, the trust found that although there was no evidence that the outcome would have been any different and this was supported by the inquest’s findings which said Tily’s death was due to natural causes, there were areas where improvements could be made and these have since been put in place. Everyone involved in Tily’s care was deeply upset by the events and we send our condolences to her family.”