1. ITV Report

Parents call for NHS guidelines review after death of baby daughter

The parents of a baby born on Boxing Day in 2011, but who died just three-days later, are calling for a review into whether NHS Guidelines are consistently applied, holiday resources and safety net arrangements following the death of their daughter.

Poppy died three days after being born at Calderdale Royal Hospital

Dr Natalie Powell gave birth to Poppy at Calderdale Royal Hospital over two weeks past her due date. The Trust's interpretation of NHS Guidelines led to Natalie being admitted to a midwife unit rather than the central labour ward, which meant that continuous fetal monitoring was not available during labour.

There was a delay in detecting a prolonged drop in Poppy's heart rate during labour and delivering her. She required intubation when she was born as she wasn't breathing.

Doctors informed Natalie and her husband, Nicholas Powell, that it was highly unlikely that Poppy would survive and if she did, she would have severe brain damage and would require extensive care.

Poppy was taken off her ventilator on the 29th December, 2011, and died shortly afterwards the same day.

Poppy's parents instructed expert medical negligence lawyers to investigate her death. The legal case has now been settled out of Court for an undisclosed five-figure sum, but the Defendant, Calderdale and Huddersfield NHS Foundation Trust did not admit liability at any stage.

Natalie and Nicholas are now keen for lessons to be learnt from Poppy's death to ensure that others do not have to go through the traumatic experience they suffered.

Losing Poppy was the hardest thing I've had to face in my life. All the way through the pregnancy, I was told that she was healthy and I was a 'low-risk" pregnancy.

However the more overdue Poppy went, the more worried I became about potential risks to the pregnancy.

I was reassured by staff that it would be safe to continue monitoring Poppy rather than undergo induction.

However, when a problem did arise the staff weren't prepared for it because they never seemed to anticipate something might go wrong.

– Dr Natalie Powell

Natalie was originally booked to be induced at 8am Christmas morning, when she was exactly two weeks overdue. However, following a discussion with a midwife on Christmas Eve this was cancelled and changed to a monitoring appointment with a midwife. At 5pm Christmas Day, Natalie and Nicholas arrived at Calderdale Royal Hospital where Natalie received between 20 and 30 minutes of cardiotocography (CTG) and blood pressure monitoring. A CTG is used to measure a baby's heart rate.

NHS Guidelines state that when a woman is 42 weeks pregnant, she should be induced or offered increased monitoring, including scanning, to check the wellbeing of both mother and baby.

The important issue of holiday resources is another one Natalie and Nicholas want to raise awareness about. The hospital did not take the holiday period into account, which meant that Natalie was unable to undergo the scanning recommended by NHS Guidelines. In retrospect, they believe that holiday resources were a significant factor prompting the discussion to cancel the planned induction.

If Natalie had gone into labour outside of the holiday period, full staffing and resources would have been available to help staff co-ordinate an effective management plan. Natalie and Nicholas firmly believe that if the NHS is not going to apply its own guidelines consistently across its NHS Trusts then any departures should only be undertaken with senior medical input, appropriate planning and ensuring that safety net resources are in place.

Natalie and Nicholas were left completely devastated by the tragic loss of their first child, Poppy.

Now the legal case is finished, they are keen to ensure that lessons are learnt from this terrible ordeal in order to improve patient safety in the future and hopefully reduce the risk of other parents from suffering the way they have.

Their experience highlights the need to ensure that guidelines are adhered to, first and foremost. If necessary, any decision to depart from protocol should be properly assessed by senior staff in advance and fully take into account the impact of any holiday period on resources. This issue needs to be addressed within the NHS on a national level.

– Kevin Saul, the expert medical negligence lawyer at Irwin Mitchell

I would like to offer my sincere condolences and apologies to Dr and Mr Powell for the loss of their baby Poppy.

We are absolutely committed to delivering the safest care to mothers and babies across all of our maternity units.

Women labour and birth 24 hours a day, 7 days a week, so to ensure safe care the number of midwives and obstetricians working is the same during any holiday period as at any other time.

Dr Powell gave birth to Poppy in 2011 and at that time, ultrasound scanning was only available over the holiday periods in emergency situations.Since then, Calderdale and Huddersfield NHS Foundation Trust has begun a programme to train midwife and doctor ultrasonographers who will provide an extended local service.

If Dr and Mr Powell have any outstanding questions they feel they would like to discuss, we would always be happy to meet with them.

– Anne-Marie Henshaw, Head of Midwifery , Calderdale and Huddersfield NHS Foundation Trust