Mum Joins Medical Negligence Lawyers At Irwin Mitchell In Calling For Lessons To Be Learned

A grieving mum is calling for lessons to be learned after medics missed opportunities to recognise her baby was in distress before her death. 

Zoe Wall’s daughter, Lily-Ann, was pronounced dead around 20 hours after the mum had been admitted to Walsall Manor complaining of reduced movement of her baby over the previous day.

Midwifery staff 'misread heart scan readings'

Midwifery staff carried out several scans to monitor Lily-Ann’s heart rate but misinterpreted readings and were falsely assured she was not in distress, an NHS investigation report found. 

After Lily-Ann was found to have died in the womb, Zoe had to deliver her. She was induced, spending nearly 29 hours in labour during which following complications, a natural delivery had to the abandoned. Lily-Ann was delivered by caesarean section during which Zoe lost nearly four pints of blood. 

Medical negligence lawyers investigate Walsall family's maternity care

Following Lily-Ann’s death Zoe, of Walsall, instructed expert medical negligence lawyers at Irwin Mitchell to investigate her care and help her access the specialist support she requires. 

Zoe, 35, has now joined her legal team at Irwin Mitchell in supporting Baby Loss Awareness Week. They are also calling for lessons to be learned to improve maternity care. 

It comes after a serious incident investigation report by Walsall Healthcare NHS Trust, which runs Walsall Manor Hospital, concluded the “root cause” of the incident “was as a result of multiple successive misinterpretations of warning signs and alerts” in reading scans of Lily’s heart rate. Staff did not identify signs that Lily-Ann could be in “fetal compromise”.

Report finds missed opportunities to deliver Lily-Ann

The report found that the results of an initial heart rate scan when Zoe attended hospital showed signs Lily-Ann was in distress. This was a “missed opportunity” by staff to identify Lily Ann’s condition which meant she should have been delivered by emergency caesarean “without further delay.”

Expert Opinion

“This is a truly tragic case in which worrying issues in the care Zoe and Lily-Ann received have been identified in the Hospital Trust’s own report.

“Zoe has been left devastated by the events that unfolded and Lily-Ann’s death and understandably has a number of concerns.

“While nothing can ever make up for her loss we’re determined to provide her with all of the answers she deserves.

“Sadly through our work we continue to see too many families who have been left trying to pick up the pieces as a result of issues in maternity care.

“Every second counts when delivering babies in distress and it’s now vital that lessons are learned to prevent other families having to endure the pain Zoe is going through.

“Patient safety should be the fundamental priority and we continue to campaign for improvements in maternity care.” Eleanor Giblin

Maternity care: Zoe Wall's story

Zoe, who has a son, Joshua, aged 10, was classed as a high risk pregnancy. She had been booked in to undergo a caesarean section on 22 July, 2021, at 38 weeks.

She attended the maternity unit at Walsall Manor Hospital at around 12.20pm on 19 July last year, complaining of reduced movements from Lily-Ann for 24 hours. 

Midwives started a computerised cardiotocography (CTG) scan on which they recorded the heart rates of Zoe and her baby. Due to the similar readings this was referred to a Registrar and an ultrasound carried out. 

Around an hour later a further heartbeat scan was started. A midwife believed the scan had recorded heart rates for mum and baby. 

That afternoon Zoe’s care and scans were reviewed by a consultant and a decision was made to admit Zoe as an inpatient for observations. 

At 11pm a midwife tried to listen to Lily-Ann’s heart rate but couldn’t find one. Following a further scan and ultrasound staff couldn’t find a heartbeat. 

Following further tests Lily-Ann’s death was confirmed at 9am on 20 July. Zoe requested a caesarean but was encouraged to attempt to deliver Lily-Ann naturally, the serious investigation report said.

Zoe in labour for 29 hours 

Zoe was induced at 12.05pm on 20 July. Following complications in delivery on 21 July, medics transferred Zoe to theatre for a caesarean at 3.40pm. Lily-Ann was born at 4.50pm weighing 9lb 4oz. During surgery Zoe lost nearly four pints of blood, the report said. 

The absence of changes in Lily-Ann’s heart rate during the initial scan after Zoe attended hospital showed signs the baby could be in distress, the report found. It added that during the follow up scan an hour later it was likely that only Zoe’s pulse was being recorded and the “alerts and prompts to alert midwifery staff to this had been misunderstood or not recognised.”

The consultant review on the afternoon of 19 July “was a further example of a misinterpretation leading to a false assurance that the CTG was deemed normal,” the report added.

It recommended all doctors and midwives working in obstetrics “must have a clear understanding” of how to interpret a computerised CTG. 

Zoe's agony over Lily-Ann's death

Zoe said: “Everything went generally well during my pregnancy with Lily-Ann but it was decided quite early on that I would have a c-section due to her size. 

“When I went to hospital I had noticed that Lily-Ann’s movements had slowed down. I could still feel her and she was still responding to me but I thought perhaps she was ready to come out as I was getting so close to the end of my pregnancy. 

“When I was told I was going to be kept in hospital I asked if that’s the case could my C-section be brought forward but I was told I had to wait until my scheduled date.

“As the evening went on I thought Lily-Ann’s movements had slowed more. By this point I was genuinely concerned because it felt like nothing was happening. 

“When I was told that night that they couldn’t find a heartbeat and to prepare for the worst, I couldn’t speak. I was so devastated and went into shock. Waiting for the scan to confirm Lily-Ann had died was agony. I was hoping and praying it wasn’t the case as when my Mom had me she had been told they couldn’t find my heartbeat. 

“When I finally heard the words that Lily-Ann had died I felt empty. Giving birth to Lily-Ann was traumatic, both physically and emotionally. I spent some time with her and had her christened but I felt so empty leaving hospital without her.  

“I never thought this would happen to me. I had so many hopes and dreams for the future and here I was leaving hospital alone without my baby girl. 

“For a long time I blamed myself for everything that happened and it was difficult not to think whether I could have done something different. I don’t think I’ll ever get over the pain of losing Lily-Ann and only wish she was at home with me and her brother growing and developing. 

“However, by speaking out I just hope that improvements in care can be made and other parents don’t have to go through what I have.

“Over the last few months I’ve had the support of friends and family and have attended a SANDS help group. People who have experienced baby loss shouldn’t have to suffer alone as help and support is available.”

Baby loss support available

Baby Loss Awareness Weeks runs from 9-15 October. More information can be found on the websites of the stillbirth and neo-natal death charity SANDS and the Lily Mae Foundation.

Find out more about our expertise in supporting families with concerns about maternity care at our dedicated medical negligence section. Alternatively to speak to an expert contact us or call 0370 1500 100.