Walsall mother calls for lessons to be learned after hospital stillbirth trauma

Zoe Wall’s daughter, Lily-Ann, was pronounced dead around 20 hours after the expectant mum had been admitted to Walsall Manor Hospital on July 19 last year, complaining of reduced movements from her baby.

The 35-year-old, of Walsall, was classed as a high risk pregnancy and had been booked in to undergo a caesarean section on July 22, 2021.

An NHS investigation report has revealed that midwifery staff carried out several scans to monitor Lily-Ann’s heart rate, although misinterpreted readings and were falsely assured she was not in distress.

Walsall Healthcare NHS Trust, which runs the hospital, admitted errors in care and said changes had since been made following the investigation.

The serious incident investigation report by the Trust, concluded the “root cause” of the incident “was as a result of multiple successive misinterpretations of warning signs and alerts” in reading scans of Lily’s heart rate.

It said that staff did not identify signs that Lily-Ann could be in “fetal compromise”.

The report found that the results of an initial heart rate scan when Zoe attended hospital showed signs Lily-Ann was in distress – a “missed opportunity” by staff to identify Lily-Ann’s condition which meant she should have been delivered by emergency caesarean “without further delay".

After her baby was found to have died in the womb, Zoe had to deliver her.

She was induced, spending nearly 29 hours in labour.

But following complications, a natural delivery had to the abandoned and Lily-Ann was delivered by caesarean section during which Zoe lost nearly four pints of blood.

Following Lily-Ann’s death, Zoe instructed lawyers at Irwin Mitchell to investigate her care and help her access specialist support.

Zoe, who has a son, Joshua, 10, is now calling for lessons to be learned to improve maternity care.

Speaking out during Baby Loss Awareness Week, she said: “Everything went generally well during my pregnancy with Lily-Ann but it was decided quite early on that I would have a c-section due to her size.

“When I went to hospital I had noticed that Lily-Ann’s movements had slowed down. I could still feel her and she was still responding to me but I thought perhaps she was ready to come out as I was getting so close to the end of my pregnancy.

“When I was told I was going to be kept in hospital I asked if that’s the case could my C-section be brought forward but I was told I had to wait until my scheduled date.

“As the evening went on I thought Lily-Ann’s movements had slowed more. By this point I was genuinely concerned because it felt like nothing was happening.

“When I was told that night that they couldn’t find a heartbeat and to prepare for the worst, I couldn’t speak. I was so devastated and went into shock. Waiting for the scan to confirm Lily-Ann had died was agony. I was hoping and praying it wasn’t the case as when my mom had me she had been told they couldn’t find my heartbeat.

“When I finally heard the words that Lily-Ann had died I felt empty. Giving birth to Lily-Ann was traumatic, both physically and emotionally."

She said she spent some time with her and had her christened but felt empty leaving hospital without her baby.

“I never thought this would happen to me," she added.

"I had so many hopes and dreams for the future and here I was leaving hospital alone without my baby girl.

“For a long time I blamed myself for everything that happened and it was difficult not to think whether I could have done something different. I don’t think I’ll ever get over the pain of losing Lily-Ann and only wish she was at home with me and her brother growing and developing.

“However, by speaking out I just hope that improvements in care can be made and other parents don’t have to go through what I have.

“Over the last few months I’ve had the support of friends and family and have attended a SANDS help group.”

Eleanor Giblin, specialist medical negligence lawyer at Irwin Mitchell, said it was a "tragic" case.

She added: “Every second counts when delivering babies in distress and it’s now vital that lessons are learned to prevent other families having to endure the pain Zoe is going through.

“Patient safety should be the fundamental priority and we continue to campaign for improvements in maternity care.”

The investigation report recommended all doctors and midwives working in obstetrics “must have a clear understanding” of how to interpret a computerised cardiotocography (CTG) scan.

Carla Jones-Charles, director of midwifery, gynaecology and sexual health at Walsall Healthcare NHS Trust, offered "sincere condolences" to Ms Wall.

She said: “A thorough investigation found that the CTG was misinterpreted as the baby’s heartbeat was very close to her mum’s. We want to do all we can to avoid such error.

“We have changed the way we teach fetal heart monitoring and an external review by NHS England around these issues was positive; highlighting our work as good practice for other units.

“We know that the bereavement care and support we gave to this mum was high-quality and want to assure her that this support is always there for her if she needs it as she comes to terms with her loss.”