Barts Health NHS Trust Apologises After Failures in Care Lead to Stillbirth of Baby Girl

Investigation Reveals Multiple Failures in Care

An investigation by the Healthcare Safety Investigation Branch (HSIB) revealed serious issues in HC’s care. Risk assessments were inadequate, and staff were unaware of tools like the online birthweight centile calculator, which could have flagged the baby’s small size.

HC was not prescribed aspirin, a medication that might have reduced the risk of growth problems, nor was she referred to an obstetric team to create a tailored birth plan when the baby’s small-for-gestational-age diagnosis was made.

During labour, staffing shortages and a lack of one-to-one monitoring delayed the start of continuous fetal monitoring. As a result, the baby’s heart rate was not observed during critical periods. HC went on to experience a uterine rupture — a complication during pregnancy where the uterus tears open.

In a letter to HC’s solicitor, the Trust apologised for the “shortcomings in the care” provided.

Calls for Change Following Devastating Loss

The HSIB report made several recommendations to prevent similar tragedies, such as assigning a named obstetric consultant to high-risk pregnancies, ensuring clinical assessments are completed before labour inductions, and addressing barriers to following established guidelines. It also called for robust systems to ensure safe care during staff shortages.

Despite these recommendations, HC has expressed doubts about the sincerity of the apology and said she has not received any reassurance that the necessary changes have been implemented.

“When they told me I had to be induced in just a couple of days, it set off a chain of events,” HC said. “I have an older son, and I needed to arrange childcare. The baby’s father also had to organise time off work. But when the day arrived, I called to find out when we should come in, and they just said they’d let us know. It wasn’t until 9pm that we got the call. By then, I was exhausted and scared.

“When my labour started, the pain was overwhelming. I kept telling the midwife, but no one was listening. Then I felt this huge ripping sensation in my stomach. I was in agony and knew something was terribly wrong. I told them repeatedly, but they just said it was normal.

“I knew it wasn’t. They didn’t do anything to check on the baby. By the time they finally did, it was already too late. I was devastated. The lack of communication afterwards only made it worse—I was left feeling completely confused and angry about what had happened.”

Legal Action and the Push for Maternity Care Reform

HC has since instructed Simpson Millar’s medical law team, led by Sanah Iqbal, to investigate the events surrounding her baby’s death and hold the Trust accountable.

The trust went on to admit that there was a delay in starting continuous electronic fetal monitoring when HC started to contract and that there was also a delay in transferring her to the labour ward, stating that ‘on the balance of probabilities, but for the above admitted negligence’, the stillbirth ‘would have been avoided’.

Kelly Withers, another birth trauma expert at Simpson Millar, who worked alongside Sanah, described the case as heartbreaking. “The HSIB report identified multiple significant failures in the care our client received during her labour. She is understandably devastated and angry by what can only be described as an unimaginable loss. Whilst the Trust’s apology is a step forward, it must be followed by meaningful actions to ensure no other family endures such a tragedy.”

HC continues to struggle with rebuilding her trust in the healthcare system and fears her ethnicity may have influenced the care she received. Her experience reflects wider concerns highlighted in data from MBRRACE-UK, which shows Black women are 2.8 times more likely to die during or shortly after pregnancy compared to white women. South Asian and Black women also face higher rates of stillbirth and complications.

“Be there for the patient. Listen carefully. Your words and actions matter more than you can imagine,” HC urged. “I can’t help but wonder if my background influenced how I was treated. By sharing my story, I want to highlight the urgent need for change so no other woman, especially from a minority background, has to experience this.”