Pair And Medical Negligence Lawyers Speak After Hospital Trust Tells Inquest Boys Died Following Failings In Care

The parents of twins who died following an emergency caesarean are calling for lessons to be learned after an inquest heard they died following failings in care. 

Harry and Henry Jackson were delivered on 17 June, 2021, after doctors at the Jessop Wing in Sheffield became concerned about their heart rates. Harry was delivered stillborn. Moments later Henry was born in a poor condition. He died aged six days. 

Shortly before the emergency procedure their mum Siobhan Weir, who had been re-admitted to the hospital the day before, had been diagnosed with pancreatitis.

Medical negligence lawyers support Sheffield family

Following their deaths, Siobhan, 22, and Luke Jackson, 24, of Wadsley, Sheffield, instructed expert medical negligence lawyers at Irwin Mitchell to help secure answers and support them through an inquest into Henry’s death. No inquest has been held into Harry’s death as he was stillborn. 

An inquest at Sheffield’s Medico-Legal Centre was told that Siobhan Weir was admitted to Sheffield’s Jessop Wing hospital three times between 9 June and 16 June, 2021, complaining of severe vomiting. 

Inquest hears evidence of Jessop Wing maternity care

Upon her third admission at 33 weeks pregnant, Siobhan also complained of abdominal pain. It was so severe she could not tolerate the monitoring of her babies’ heart rates, a serious incident investigation report said. The report by Sheffield Teaching Hospitals NHS Foundation Trust, which runs Jessop Wing, following both boys’ deaths was presented to the inquest. 

Siobhan was diagnosed with severe nausea in pregnancy at around 9am on 16 June but medics did not consider any other causes for her symptoms, the report said. An amylase test to establish whether Siobhan had gastrointestinal illness wasn’t requested until nearly seven hours later and the results not viewed until nearly 10.20am the following day. 

Siobhan continued to suffer with sickness throughout 16 June. She struggled to tolerate further heart rate scans of her twins because of pain. However, the report found there was no clear record that the risks associated with not having her babies’ heart rates monitored was explained to her.

Results of her observations were not referred to for an obstetric review. 

On 17 June Siobhan was diagnosed with pancreatitis. A scan of her babies’ heart rates was classed as abnormal and an emergency caesarean performed. Harry was delivered stillborn. Moments later Henry was born in a poor condition. He died aged six days. 

Report finds 'missed opportunities' and 'failures' in maternity care

The serious incident investigation report found there were “missed opportunities to investigate” the cause of Siobhan’s persistent sickness during her pregnancy. 

The report also found there was “a failure to escalate” that Siobhan was declining monitoring of her babies. Midwifery teams also did not recognise deterioration in Siobhan’s observations on the night of 16 June, and this was not escalated that night.

The report found that a delay in requesting and analysing the amylase result and not escalating Siobhan’s care to specialist obstetricians contributed to Henry and Harry’s deaths. 

During the inquest representatives of the Hospital Trust said there were ‘failings’ in care and ‘missed opportunities’ and that the twins would have survived had they been delivered sooner.

The inquest concluded had it been recognised Siobhan’s condition was deteriorating sooner, a scan of her babies’ heart rates would have started sooner. It is likely a caesarean would have been performed earlier and that Henry would have survived. 

Sheffield Hospital Trust apologises to parents during inquest

Assistant coroner Tanyka Rawden recorded a narrative conclusion in which she criticised the Trust for its care. However, after hearing the Trust was taking measures to improve care she decided to await its update in the autumn as to the work that has been done before deciding whether to issue a Prevention of Future Deaths Report.  

During the hearing the Trust apologised to Siobhan and Luke. 

Expert Opinion

“This is a truly heartbreaking case which has had a profound impact on Siobhan, Luke and the rest of the family who understandably have been left traumatised by the events that unfolded.

“For more than a year they’ve had a number of concerns about the care Siobhan received and whether more could have been done to prevent Henry and Harry’s deaths.

“While nothing will ever make up for the pain Siobhan and Luke continue to face we’re pleased that we’ve at least been able to help provide them with some of the answers they deserve.

“Sadly through our work we continue to see the catastrophic consequences that families are left to face following issues in maternity care. Behind each case is a human story of how families have been devastated.

“The inquest and the Trust’s own investigation have highlighted worrying areas in the care Siobhan received. While we welcome the Hospital Trust’s openness during the inquest and pledge to make changes, it’s now vital that these are introduced and upheld at all times to improve maternity safety.

“We continue to represent too many families, not just in Sheffield, but across the country who have been affected by maternity issues. We remain committed to supporting families we represent to provide them with the answers and support they deserve as we also continue to campaign for improvements in maternity care nationally.” Rosie Charlton - Senior Associate Solicitor

Siobhan, a care home worker, said: “We were delighted when we found out we were going to become parents. We felt incredibly blessed and even more so when we found out we were expecting twins. 

“When I was in hospital I was poorly but at no point did I feel that the severity of the situation was explained to me. 

“When I went into hospital for the third time I never expected what would happen. More than a year on we still can’t really believe what happened and how both Harry and Henry didn’t make it. 

“It’s impossible to put into words how difficult it remains trying to come to terms with how Henry and Harry died. It’s difficult not to think how things could be different and both the boys could be at home growing up and starting to cause mischief. 

“Nothing will ever fill the void in our lives. I don’t think we’ll ever get over losing Harry and Henry and we will continue to think about them every single day. They will always be a part of our family and we’ll never stop loving them.

“I hope that by speaking out others who find themselves in a similar situation don’t have to suffer alone. Help and support is available.”

Find out more about our expertise in supporting families affected by baby loss or birth injury at our dedicated birth injuries section. Alternatively to speak to an expert contact us or call 0370 1500 100.