"In labour with morphine and no monitoring."

About: Fiona Stanley Hospital

(as the patient),

I was in a lot of pain and starting contractions when we arrived at the hospital at 1am, they checked me and my baby using CTG (Cardiotocography) and USS (Ultrasound Scan). FHR (Foetal Heart Rate) was 153 bpm (beats per minute), apparently midwives said I was in early labour and I was 2cm dilated only. She wanted to send me home, but we stayed because of my pain. After arriving at the hospital 2 staff told us they were busy. If I went home I would have to call them again and if they were still busy I might have had to refer to the other hospital. 

Midwives administered me morphine and they allowed me to stay at the hospital, but after that no further monitoring was done until 5am. When another midwife checked me using CTG, USS she found out my baby had no more heartbeat. We believe the treatment we got was so bad and unacceptable because we lost our baby. 

My concern is if they monitored me well and I had the CTG attached to me they could have saved our baby, because this would have alerted them if our baby was in distress.  Especially because I was administered morphine. 

It was a nightmare for us because my pregnancy seemed to have no problems all through. My antenatal check-ups, tests, scans, were all good. 

Whilst I was at the hospital during labour, I felt that the midwives were not monitoring me and our baby, as they should have been doing especially after I was administered morphine. But I thought - I have to put my trust in the hospital staff to take care of me and our baby. It is difficult for us to come to terms with the fact that we believe our baby's death could have been avoided. In our opinion, there were so many missed opportunities. We believe they could have done something, but they didn't.

I delivered our baby 38+3days gestation, 6pounds, 8oz, 151cm and it was an IVF pregnancy. 

I hope because of what happened to us they will be more alert and they will not follow what they see outside of the patients.

I believe it's not a pattern if the patient can still talk and stand, so it means they're still okay. I believe they have to be more vigilant with pregnant women presenting with low risk/high risk pregnancies to ensure that all plans of care are appropriate and ensure babies are fine and monitored all the way.

An apology won't make things right. It won't bring our baby back. But by identifying what we believe are failings and lessons from our baby's death, I hope steps will be taken to improve maternity care and ensure no other parent loses a baby the same way as us.

Post mortem will help us to find what the cause of death was, but it won't change the fact that I believe the way they treated us was unacceptable.

Responses

Response from Tim Leen, Service Director, Service 3, Fiona Stanley Fremantle Hospital Group, South Metropolitan Health Service

picture of Tim Leen

Dear So this doesn't happen again,

Firstly, I would like to sincerely express my deepest sympathy for the loss of your child. This is obviously a very sad time for you and your family.

I wanted to let you know I have personally looked into the care you received during your time at Fiona Stanley Hospital and the circumstances surrounding your treatment and experience are being thoroughly investigated by a review panel of clinical experts. I also understand you have already been in contact with Patient and Family Liaison, we really welcome this opportunity to work with you and support you and your family during this difficult time.

I would like to meet with you to better understand what occurred during your stay with us and I invite you to contact me directly on 6152 3121 so we can organise a time to sit down and talk about your experience.

The loss of a child is incredibly distressing and the heartbreak can be immeasurable for parents and family members. You may wish to access support from SANDS (miscarriage, still birth and newborn death support), they can be contacted on 0424 340 115 or alternatively you can visit their webpage on www.sandswa.org.au. SANDS offers a helpline manned by volunteers who have been through the devastating loss of a baby in the past. The Helpline is available 24/7 and can be contacted on 1300 072 637

I look forward to hearing from you.

Kind regards

Tim Leen

A/Executive Director

Fiona Stanley Fremantle Hospital Groups

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