An Accrington mother who raised concerns prior to the birth of her child said she felt “ignored” by the health trust after her baby died.
Ivy Rose James was born on November 30 at Burnley General Hospital and died after getting pneumonia in her lungs before birth.
An inquest at Preston Coroners Court heard how Ivy’s mother, Lisa, had a weakness of her cervix, which had allowed the infection in, and the risk was heightened by the presence of E. coli.
Before the birth, Lisa had several consultations with Dr Sarah Davies, who had deemed her birth to be high risk due to a history of difficulties during her other pregnancies.
Dr Michael Cocker, consultant obstetrician and perinatal lead at East Lancashire Hospitals Trust, highlighted Lisa had previously had difficulties and a number of premature births.
Lisa had a cervical stitch, but this had fallen out in the weeks leading up to her birth.
She visited the hospital on two occasions, November 21 and 24, for CTG scans, which did not indicate any major concerns.
Coroner Kate Bissett read a statement from Lisa, which was given to the medical examiner shortly after the birth of Ivy.
It said: “Mum [Lisa] has no concerns about neonatal care, but she felt she hadn’t been listened to by medical staff before her daughter's birth.
“She had been to the hospital twice. She reported bleeding [but was] not examined, and her blood pressure was up, but she was only given medication to control her blood pressure.
“She kept telling them that something was wrong. She didn’t receive any antibiotics, and the following day she was told that her blood had been abnormal.”
Dr Cocker apologised and said it was disappointing Lisa had this experience and her concerns were ignored.
He also indicated that, in hindsight, there were subtle hints of infection, but said that if they had tried to deliver the baby on either of her previous visits, the chance of survival would have been minimal due to Ivy being born so prematurely.
Concerns were also raised as to whether she could have been moved to the central birthing suite at an earlier stage; however, Ms Bissett said it was unclear if that would have improved Ivy's chance of survival.
Lisa said: “At the time, the doctors had their own separate issues, and they didn’t bring it together.
“Even though I have a history, no one brought it together, and it was separate pieces, and if someone had brought it together, it would have made a difference.
“I knew that was going on, so why didn’t the doctors know?”
Dr Cocker added Lisa knew her body best and healthcare teams need to take the concerns of pregnant women seriously, and it was something he would feed back to the hospitals.
On the night Ivy was born, a statement from Dr Andrew Cox said staff did their "absolute best" to keep her alive, which included her being placed on a ventilator and intubated.
His statement said: “I want parents to know how hard we tried to keep their baby alive that night, and besides speaking to the parents, I did not leave Ivy’s side for the entirety of that night.”
READ MORE: Inquest opens into death of "beautiful boy" killed by falling gravestone
READ MORE: Parents not told of baby daughter's critical condition before her hospital death
Catherine Sansbury, the quality and safety lead for midwifery at East Lancashire Hospitals NHS Trust, said that since Ivy’s death the trust has introduced an escalation toolkit, which looks at identifying signs of infection as well as focusing on clearer communication.
She also invited the family to share their story to help with training, so the trust can improve in the future.
Catherine said: “Can I apologise, that this is how you felt. As a midwife, I hate to hear that.
“If you wish, I could share the details with the wider team through our training scheme.”
Concluding the hearing, Ms Bissett said she had been humbled by the dignity of Lisa and her partner and it had been a pleasure to meet them both.
She also said she was in awe of Lisa’s strength of character to continue having another child despite the range of difficulties she had faced historically, and congratulated the pair on the delivery of their son, Stanley.
Ms Bissett provided the following narrative conclusion: “Ivy Rose James was born on November 30, 2023, at Burnley General Hospital at 30 weeks after foetal distress.
“She was suffering from pneumonia due to an infection in her amniotic fluid.
"Ivy did not respond to treatment and died in her mother's arms due to the infection.”
If you have been affected by this story or have had a similar experience, child loss charities including Sands, The Lullaby Trust, and Child Bereavement UK can provide specialist support.
Share