Leeds General Infirmary: Bereaved parents call for improvements to maternity care after tragic baby deaths

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A Leeds couple whose baby died just 27 minutes after being born are among the bereaved parents calling for improvements to maternity care in the city.

Fiona Winser-Ramm and Daniel Ramm were left traumatised by the death of their daughter Aliona at Leeds General Infirmary (LGI) in 2020.

An inquest last year concluded that there were “a number of gross failures” that directly contributed to her death, and Leeds Teaching Hospitals Trust acknowledged that “earlier intervention would have, on the balance of probabilities, resulted in a live birth”.

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Fiona Winser-Ramm and Daniel Ramm were left traumatised by the death of their daughter Aliona at Leeds General Infirmary (LGI) in 2020.Fiona Winser-Ramm and Daniel Ramm were left traumatised by the death of their daughter Aliona at Leeds General Infirmary (LGI) in 2020.
Fiona Winser-Ramm and Daniel Ramm were left traumatised by the death of their daughter Aliona at Leeds General Infirmary (LGI) in 2020. | Submitted

Now, Aliona's parents have joined campaigners demanding change over what they described as a lack of action to learn lessons from incidents and deaths in maternity care.

Fiona was 41 weeks into her first pregnancy when she was booked in for an induced labour. On the day of the induction, while still at home, contractions began spontaneously. She was advised by the maternity assessment centre at LGI that she could remain at home.

Contractions continued and Fiona called the maternity centre the following morning. She was concerned about her baby’s movements and that her waters may have ruptured. However, she wasn’t offered the opportunity for an assessment.

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The next day, contractions had increased in strength and frequency, and Fiona was admitted to LGI. After an assessment, the baby's heart rate was categorised as pathological or abnormal. Observations continued and, shortly afterwards, the baby’s heart rate improved and was recorded as normal.

However, during the last four hours of labour, Aliona’s heart rate deteriorated again. This information was withheld from her parents, despite it being recorded in the medical records that they were informed.

During the early hours of New Year’s Day in 2020, Aliona was born in a poor condition. She was unable to be resuscitated and was pronounced dead, aged 27 minutes.

An inquest last year concluded there were “a number of gross failures of the most basic nature that directly contributed to Aliona’s death”. The trust has admitted liability and acknowledged “earlier intervention would have, on the balance of probabilities, resulted in a live birth.”

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Fiona and Daniel, aged 38 and 40, have urged parents to challenge and questions medics if required.

She said: “What should have been the happiest moment of our lives became the most traumatic experience and something I wouldn’t wish on anyone.

“If the pain of trying to come to terms with Aliona’s death wasn’t bad enough, it then felt like we were left facing a complex system in an attempt to secure answers.

“It felt like a battle to have our voice heard and secure the justice for Aliona that she deserved. We felt that the Trust wasn’t entirely transparent with us and withheld information about our girl.

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"Following Aliona’s death, the Trust tried to make us feel like a problem that had to be managed rather than listening to our concerns. There was no empathy whatsoever and the shocking thing is that we continue to hear too many stories of how families have been let down by failings in care and common issues run through what happened.

“We’ve heard of parents trying to raise concerns about their care but they’re either not listened to or dismissed. In many cases if we’d been listened to our children would still be here.”

She continued: “While time moves on the pain of losing a child – the most precious gift in the world – never eases. What we endured is etched in our memories forever. I often replay those events in my mind longing for things to be different while knowing nothing can bring Aliona back. We have to blow out her candles on her birthday because she isn’t here to be able to do it herself.

“We believe there needs to be an overhaul of the system. The CQC may say that maternity services in Leeds are good. However, we believe this doesn’t translate to good on the ground. One of the criteria for the good rating is a survey asking for parents’ views where care scored well.

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“We feel the data is skewed and inspection gradings are being given when those of us who’ve received the worst experiences aren’t really being given a voice or having our experiences taken into consideration; bereaved parents are totally omitted from the survey.

“Other feedback that people are invited to complete rely on people choosing to do so, and it’s just not feasible for those grieving for their child to be expected to participate. We believe that the CQC’s ‘good’ rating is misleading and is not reflective of the experience we, and others, have had, frequency of incidents and repetitive themes that are occurring in Leeds.

“This also sits with the recent interim findings of a review into the CQC. The new Secretary of State for Health and Social Care, Wes Streeting, has even said that ‘the CQC is not fit for purpose’ and that he would take CQC ratings with a pinch of salt.

“People have the right to challenge doctors and make decisions about their care and what’s best for them. It’s vital the national scandal of maternity safety is improved but also families feel empowered to ensure their needs are met as doing so will improve care for others.

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“People shouldn’t have to go through the trauma of baby loss alone. We’d encourage others to come forward and share their stories to help affect change.”

Fiona and Daniel are one of the families represented by specialist medical negligence lawyers at Irwin Mitchell, all of whom were under the care of The Leeds Teaching Hospitals NHS Trust when their babies suffered serious injury or died.

They are speaking publicly as a group for the first time to raise awareness of their concerns about maternity services in Leeds.

Katie Warner, an expert medical negligence lawyer at Irwin Mitchell, said: “Sadly through our work we continue to see too many families left devastated by failings in maternity care.

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“Behind every statistic is a life lost, or severely compromised, and a family struggling to pick up the pieces.

“Understandably the families we represent have had concerns about the care they received under Leeds Teaching Hospitals NHS Trust but also regarding whether all possible lessons are being learned to improve maternity safety given the recurrent nature of the mistakes being made.”

She added: “"While maternity services in Leeds have been rated as a good by the Care Quality Commission, our clients remain concerned about the actual care families are receiving.

“They believe while paperwork is in place, these ‘tick boxes’ for when inspectors visit and care on the ground is different.

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“Our families’ concerns include staff communication with families, including around the heart-rate monitoring of babies and not listening to mums’ concerns.

“All the families want is to ensure is that, where appropriate, no stone if left unturned in ensuring effective and lasting change is introduced to uphold patient safety for families.”

Responding to the concerns, Magnus Harrison, the Chief Medical Officer at the trust, said: “We extend our deepest sympathies to the parents who have lost their babies.

“We recognise that Baby Loss Awareness Week must be particularly difficult for these parents and families and our thoughts are with them.

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“We want our families to know that we are dedicated to patient safety, and whilst these instances fell below the standard of care we expect, we take every incident seriously and study them to reduce the risk of them happening again.”

He added: “We work closely with independent experts to investigate such incidents thoroughly and implement recommendations, and remain committed to ensuring we provide safe, integrated care across our maternity services. We are proud of our good CQC rating and positive patient experiences shared in the maternity survey results.”

Two mums who lost their babies have now set up an independent support group for families impacted by Leeds maternity services.

The Leeds Hospitals Maternity Family Support Group has been set up by Fiona Winser-Ramm and Lauren Caulfield.

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The group is open to anyone affected by baby loss, parents whose children have been injured during birth or mums who have suffered injury during childbirth. It is holding its first quarterly drop-in session on Wednesday (October 16) between 10am and 1pm at the office of Irwin Mitchell at 4 Wellington Place. Those wishing to attend should email [email protected] to register.

Lauren Caulfield is another parent who asked lawyers at Irwin Mitchell to investigate and secure answers after her daughter Grace was delivered stillborn at LGI.

Lauren Caulfield and then partner Arron Kilburn contacted Irwin Mitchell after their daughter Grace was delivered stillborn at LGI.Lauren Caulfield and then partner Arron Kilburn contacted Irwin Mitchell after their daughter Grace was delivered stillborn at LGI.
Lauren Caulfield and then partner Arron Kilburn contacted Irwin Mitchell after their daughter Grace was delivered stillborn at LGI. | Submitted

Lauren attended hospital in March 2022 after her contractions started. Medics could not find a heartbeat.

Following Grace’s death, Lauren, 26, and her then partner Arron Kilburn, 36, agreed to a post-mortem examination. However, LGI staff lost the placenta before it could be tested and potentially provide more answers.

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A post-mortem examination found Grace died two or three days before birth after being staved of oxygen. However, tests were unable to establish why she suffered a sudden lack of oxygen.

During her pregnancy, Lauren was under the care of Leeds Teaching Hospitals Trust and Bradford Teaching Hospitals Trust.

A Health Safety Investigation Branch report found several care issues including Grace’s growth not being consistently monitored because of the use of different systems between the two Trusts.

There were two occasions when growth scans should have been requested but referrals were not made, the report found.

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It added that if Grace's growth rate been correctly diagnosed, it “may have altered the outcome for the baby”.

Lauren said: “Every day and living with the trauma we’ve been through breaks our hearts. We continue to have so many questions about not only what happened to Grace but also how the placenta wasn’t tested.

“The decision to agree to a post-mortem wasn’t easy and it now feels like we’ll never fully get to bottom of what happened to Grace and why because Leeds didn’t carry out all of the tests they should have.”

Following Grace’s death, Lauren said she didn’t receive any post-natal care for 15 days following a communication breakdown between the Leeds and Bradford Hospital Trusts.

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She added: “What happened to us that day will remain with us forever.

“Me and Arron had no support from the healthcare system and in essence imploded due to the sheer grief, sadness and pain we were experiencing with no idea on how to navigate.

“I can’t just sit back and potentially see others going through what we’ve had to.”

Heidi Mayman is another parent who suffered a bereavement. Her daughter, Lyla Morton, died after being starved of oxygen during her delivery which happened around 37 hours after her mum called LGI concerned her waters had broken.

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Heidi Mayman's daughter Lyla Morton died after being starved of oxygen during her delivery which happened around 37 hours after her mum called LGI concerned her waters had broken.Heidi Mayman's daughter Lyla Morton died after being starved of oxygen during her delivery which happened around 37 hours after her mum called LGI concerned her waters had broken.
Heidi Mayman's daughter Lyla Morton died after being starved of oxygen during her delivery which happened around 37 hours after her mum called LGI concerned her waters had broken. | Submitted

Heidi called the maternity assessment unit just after 4am on June 12 June in 2019, reporting blood and fluid loss. Earlier that night she had felt a pop and passed liquid and blood.

Heidi was told to stay at home until her contractions were every three to four minutes.

She called the unit again at 6pm and was told to stay at home. Two hours later, following a third call, Heidi was advised to attend. After an examination, she was told she wasn’t in established labour and was sent home with advice to take a bath.

Just after 2am on June 13, Heidi attended hospital for a second time. Following an assessment, she was advised she could go home for a second time but chose to stay in hospital.

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Heidi continued to be concerned about her baby. After an examination later that morning, she was transferred to the delivery suite.

In the afternoon, five readings on a computerised machine measuring Lyla’s heart rate were ‘pathological’. More than three hours after the first ‘pathological’ reading Heidi was transferred for a caesarean. Lyla was delivered in a poor condition just after 5pm.

She died aged four days on June 17 as a result of multiple-organ failure and a severe brain injury.

Heidi, 34, a hairdresser, and partner Dale Morton, 33, of Batley, asked Irwin Mitchell to investigate.

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The trust admitted a breach of duty in that during the call just after 4am on June 12, staff should have recognised Heidi’s waters had potentially broken and there was a failure to invite her to hospital for an examination.

It admitted that on the balance of probability that if Heidi’s waters had broken and she had chosen an immediate induction of labour, Lyla would have been delivered earlier than she was. Lyla would either have avoided her brain injury of her injury wouldn’t have been as severe.

The trust has paid an undisclosed settlement to the family.

Heidi said: “The hurt and pain we feel over what happened to Lyla remains as strong now as it did when she was born. We’ll always cherish those precious few days we got to spend with her.

“We just wanted to love and care for her but felt so powerless to save Lyla. She didn’t deserve to go through what she did.

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“The hardest thing to try and accept is that I tried to raise my concerns so many times, but I felt like I was ignored. Mums know their bodies and they should be listened to. It’s hard not to think Lyla would still be with us if that had happened.

“What happened to Lyla was bad enough but to keep on hearing stories of other families whose lives have been shattered because of care issues in Leeds is staggering.”

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