A woman who suffered six miscarriages lost her seventh baby after doctors delayed her caesarean section, a report has found.
Chyril Hutchinson was admitted to hospital in February 2021 with high blood pressure when she was 37 weeks pregnant with her daughter Ceniyah Cienna Carter, and was told by doctors at Mid and South Essex NHS Foundation Trust she would need a caesarean.
But the procedure was delayed as a result of staffing pressures and because Ms Hutchinson’s blood pressure stabilised. She was then told she would have to wait another two weeks for it to be carried out.
Given her previous miscarriages, Ms Hutchinson said she pleaded for her baby to be delivered earlier, but her concerns were “dismissed” and she was sent home. Days later, a scan revealed that her baby had died.
A trust investigation into Ms Hutchinson’s care found that staff had failed to properly monitor the growth of her baby, which could have indicated the need for an earlier delivery.
The internal report, seen by The Independent, also revealed that on the day Ms Hutchinson was told she should have a casaerean, the hospital was six midwives short and the department was busy – a situation the trust said “places additional pressures and possible overload on medical staff”.
However, the report concluded that staffing levels did not affect Ms Hutchinson’s care, and it did not state whether the wider failings had led directly to her child being stillborn.
Ms Hutchinson told The Independent she felt compelled to complain because, in her view, staff had “dismissed” her concerns about being discharged.
“I was relieved when a consultant told me that, because my pregnancy was high risk, she wanted to perform a C-section that day. The following morning, when I was told I was going to be discharged and not have the C-section, I was distraught. When I tried to explain how I was feeling and my concerns, I was completely dismissed by the consultant.
“I said ‘I’m not really happy about going home,’ but … [the doctor] just put a hand up like I’m in a classroom to stop me from speaking. The consultant’s words to me were ‘I’m only here for emergencies.’”
Ms Hutchinson continued: “I spent so long trying to get pregnant, and after so many miscarriages I finally thought that, with consultant-led care, I would receive the care I needed to deliver a healthy baby.
“To receive the … report and see all the failings in my care, and all the missed opportunities to deliver my daughter safely and alive, is really hard to take. My daughter should be here with me.”
Suleikha Ali, from JMW Solicitors, the legal firm that represented Ms Hutchinson, said: “Sadly, from my own experience of representing women in maternity claims over the years, they often recount the same feelings as Chyril of not being listened to, being dismissed, and their concerns not being taken seriously enough. If Chyril had been listened to, her daughter Ceniyah would be here today.
“Like many of my clients, Chyril had to make a complaint before the trust conducted an investigation into the care she received. It was only on receipt of the report that she became aware of the number of missed opportunities to save her daughter. If Chyril did not complain, would the trust have investigated?”
Denise Townsend, deputy chief nursing officer for Mid and South Essex NHS Foundation Trust, said: “We offer our condolences to Ms Hutchinson and her family, and would welcome the opportunity to apologise face to face. We have learnt a great deal from the failings that were identified in this investigation, and have already put our learning into practice with maternity staff.”
Ms Hutchinson’s story comes after the trust launched an investigation into 15 serious incidents between August 2021 and January 2022, and follows an incident in 2019 in which a woman bled to death.
According to reports by NHS Resolution, the trust paid out more than £25m across 27 clinical negligence claims related to obstetrics in 2020-21 – the second highest of any trust that year.
The trust’s maternity services are rated as requiring improvement. They were previously rated inadequate, and the trust received a warning notice in 2020 after whistleblower concerns prompted an inspection by the Care Quality Commission.