A COUPLE were denied the chance to hold their newborn baby as he died as a result of mistakes by hospital staff.
The parents were told by staff at Raigmore Hospital, Inverness, that their son had been born without a heartbeat.
But it later emerged the child had been born alive and lived for about a minute, meaning the distraught couple could have held him in his last moments.
The tragedy is revealed in a report by the Scottish Public Service Ombudsman (SPSO), which investigated a complaint by the parents.
The report said the couple – identified only as Mr and Mrs C – felt they “would never get over” not being able to hold their child while he was alive.
The baby, which was born prematurely in January 2011, also had a condition which the family were not told about.
The SPSO upheld four complaints against NHS Highland.
“Mr and Mrs C also raised concerns surrounding the birth of Baby A, including the fact that they were not informed that he had been born with a beating heart and they had not been offered the opportunity to hold him,” stated the report.
“They were also distressed that he was placed in what looked like a cardboard box.
“Mr and Mrs C also complained that, following Baby A’s birth, a subsequent consultant review was not arranged to determine what went wrong and what implications it could have on future pregnancies.”
The report said: “Mr and Mrs C complained that Baby A was born with a beating heart but they only discovered this on reading Mrs C’s medical notes at a later date.
“They complained that they had not been told prior to Baby A’s birth that this might happen.
“Mrs C says that as a mother she will never get over the fact that Baby A was born alive, that they were not given the opportunity to hold him and that he was not given the chance to die in their arms.”
Heart
The report continued: “In response, the Board acknowledged the distress that Mr and Mrs C would have experienced on discovering that Baby A had a beating heart on delivery, when they read the medical notes.
“They stated that if there is a known possibility of a baby being born alive this would be explained to the parents.
“However, on occasions, it may not be known if a baby is going to be born with a beating heart. The Board apologised to Mr and Mrs C for the trauma they had experienced as a result of this.”
A midwife recorded the baby ”was delivered at 07:15 with fetal heart beating but seemed to have passed away very quickly, within one minute of his birth”, the report said.
The Ombudsman said: “I consider that that during the birth of baby A, the Board unreasonably failed to inform Mr and Mrs C that Baby A was born with a beating heart and in doing so, Mr and Mrs C were denied the opportunity to hold Baby A while his heart was beating.”
The couple felt “traumatised” when they later learned their baby had been born with a heartbeat.
The report said it was documented in medical notes that the couple were offered the chance to hold the baby but they dispute this.
Box
“Mr and Mrs C complained that following Baby A’s birth he was placed in what looked like a cardboard box on top of a bed trolley in the delivery room,” added the report.
“They did not recall him being wrapped in a blanket, only that just a cover was placed over him. They felt that Baby A had been discarded by medical staff.”
The midwife said she recalled wrapping Baby A in a blanket and placing him in a cot, and the Ombudsman said he could not say definitively what the baby was placed in after being born.
The ombudsman upheld a complaint the couple made that an amniocentesis procedure in December 2010, where Mrs C had a needle inserted in her womb three times, was not done in accordance with guidelines.
A complaint NHS Highland “unreasonably failed to inform Mr and Mrs C that Baby A was born with a beating heart and Mr and Mrs C were not given the opportunity to hold him” was upheld.
Complaints a consultant review was not arranged and the couple were not told about baby A’s “abdominal wall defect” detected during the amniocentesis procedure were also upheld.
However a complaint that the baby was placed in a cardboard box after being born was not upheld.
Condolences
Dr Ian Bashford, medical director for NHS Highland, added: “I would also like to offer my condolences to the family.
“We welcome the independent review by the Ombudsman’s Office and fully accept the recommendations and will implement them. The care that we provided fell below the standard that we would expect and I would like to offer my sincere apologies for the distress that has caused.
“We have shared the Ombudsman’s Report with colleagues involved in the case. It is so important that we all continue to reflect and learn to make sure, as best as we possibly can, that this does not happen again.”
