Sussex hospital admits failings after baby dies at just two days old
An inquest in to Abigail Fowler-Miller’s death heard her mother Kate Fowler phoned the Royal Sussex County Hospital in Brighton[1] from her home in Hove at 9.30am on January 21 last year. She had early signs of labour from roughly 3am that day. She got through to a triage midwife who was new to the department at 10.05am.
Ms Fowler was told she should not go to the hospital and to see how her condition developed. At 3.05pm Ms Fowler contacted the hospital again saying she had experienced a discharge of blood and mucus “roughly the size of a penny”, the inquest at Brighton Town Hall heard. Coroner Joanne Andrews said it was at this point Ms Fowler should have been invited in to hospital to check on her condition.
At 4.49pm she called the hospital again and while there was no indication of a haemorrhage, Ms Andrews said hospital staff should have called her in for an assessment. Ms Andrews said NHS guidelines say that an expectant mother should be called in to hospital after three worried phone calls. At 6.45pm Ms Fowler became unwell.
Her hands became sweaty and her lips turned blue. Her partner Rob Miller called the maternity assessment unit, making contact at 6.59pm. The inquest heard that University Hospitals Sussex NHS Foundation Trust, which runs the Royal Sussex, accepted that at this stage[2] an ambulance should have been called.
Mr Miller called for a taxi which arrived at the hospital’s Millennium Wing, rather than the accident and emergency or labour departments. Ms Fowler had collapsed by the time they arrived. An emergency caesarean section was performed by the maternity registrar who had been alerted and attended the Millennium Wing.
Heather Brown, consultant obstetrician and gynaecologist on the labour ward, was not carrying the consultant pager at the time which would have notified her of the emergency unfolding in the Millennium Wing. The court heard that staff failing to carry the emergency pager was a regular occurrence as the main means of contact is through mobile phones. When Miss Brown arrived at the scene she found staff resuscitating Ms Fowler, who was in cardiac arrest, and other resuscitating baby Abigail on two chairs in the waiting room.
The court heard from Dr Theresa Kelly, a specialist in maternal medicine, who said: “Abigail was resuscitated on two chairs with no heat to keep the baby warm and no oxygen. “Because Miss Fowler and Mr Miller came in via taxi to the wrong place, they did not have any of those things there.” Ms Fowler was taken into theatre where it was discovered she had a 5cm rupture on the back wall of her uterus.
Abigail’s time of birth was 7.49pm on January 21. She died two days later. The coroner said that if Ms Fowler had been called in for an assessment at 4.49pm on January 21 then she would have remained there, rather than being sent home.
She concluded that Abigail’s life would have been “significantly prolonged” if Ms Fowler had received a caesarean section before going into cardiac arrest.