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The Report

A lot of people ask about Zak’s birth and what happened, the truth is its taken me until recently to get my head round it myself. What I thought had happened turned out to be nowhere near as bad as it was. Zak’s birth was investigated by Healthcare Safety Investigation Board or HSIB for short who are a government instructed organisation that work with the NHS to investigate all pregnancy, births and deaths after 37 weeks of pregnancy. I had to give my permission for them to investigate which I was happy for them to as I wanted a better understanding to and believe there’s something to be learned in everything. The investigation was a long process as it required interviewing every person involved in my care throughout pregnancy & labour and they also interviewed me. They then collate all their findings into a report which they sent to me for feedback and then add my comments into the final report. The report didn’t come out until Zak was nearly 11 months old and reading it was pretty shocking.

What I thought had happened was Zak pooed on his way out, he was born not breathing because he swallowed it, he was without oxygen for 11 minutes and due to the lack of oxygen to his brain he had a couple of seizures which resulted in brain damage and he is expected to have cerebral palsy because of it. Now that is what happened in a nutshell but there was also so much more I had no idea about. The report explained everything from start to finish of my labour process but it brought new information to light like; my heart rate was very high all through labour, I had sepsis through labour, they lost contact with Zak’s heart rate for the last 20 minutes of me pushing him out, but worryingly of all they had made suggestions for the trust to put some actions in place to prevent something like this happening again. The report didn’t clearly state it could have prevented what happened to Zak but it heavily implied it. It was like having the wind knocked out of me, I thought what had happened was just one of those things and couldn’t be helped but maybe it could have been? It made everything so raw again and after reading the report I was back to not sleeping, checking on Zak all through the night, crying for no reason and I just felt numb. I literally couldn’t even talk about it, there were no words.

I shared the report with my parents who were inevitably shocked and devastated, I don’t think any of us expected it to say what it did and I also shared it with Tom. I decided to ask for a meeting with the hospital to get a better understanding and some closure hopefully because I just couldn’t process any of it. HSIB attended as did the head of midwifery, senior maternity consultant and Tom came too. That meeting was the worst meeting of my life. It was worse than Tom leaving. I still don’t know how I held it together, despite a couple of tears I stayed strong and they were lovely. They talked us through the report and answered out questions fairly and honestly. The report had highlighted that my heart rate was high throughout labour around 130-140 and that this should have been picked up as a sign of something being wrong and infection. I asked what my heart rate should have been and the consultant said resting heart rate is generally around 80 but as I was in pain and only had gas and air she would probably have expected it to be around 100 in a normal labour, so 130-140 is quite a bit higher and in actual fact the last 10 minutes of my pushing my heart rate rose to 192 which is dangerously high. She actually sat there and said I could have deteriorated very quickly and I was very poorly. That led me to asking about the infection – I knew Zak had been treated for Sepsis in Bristol but assumed this was because he had swallowed his own poo – turns out he got the sepsis from me. My waters broke naturally in early labour and at some point in the later stages of labour I picked up an infection because my waters had gone but I never had any sign in the terms of coloured discharge etc. This infection led to me getting a kidney infection and ultimately the beginning of sepsis. I then passed this onto Zak and so when he was born with meconium (not uncommon) he had nothing in his reserves to fight with because he has already been fighting an infection inside me which is why he needed help breathing etc. I think we forget how fragile babies are, Zak was a big baby and should have had a lot to fight with but thanks to the infection he didn’t. Now although I didn’t have coloured discharge which is a sign of infection and meconium when I was admitted to hospital in active labour there were indicators of infection that got missed. The facts are as follows:

  • I went into hospital at 11am as my waters had broken and they did a urine test which showed I had low ketones which meant I didn’t have enough energy so I needed to drink isotonic drinks.

  • I was 2cm dilated and I was checked for infection but there was no sign. I was given a leaflet with more information about signs of infection because my waters had gone

  • They sent me home as I was still in early labour and was told to return for 5am the next day to be induced if I had not gone into active labour

  • Swindon hospital procedure is to wait 24hrs to induce if there are no signs of distress, after waters have broken. It is different in every trust e.g. Gloucestershire is 72 hrs.

  • I rang the hospital at 7pm because I had started being sick again and couldn’t even keep water down, so was concerned I couldn’t get the isotonic drinks in so would have no energy to deliver. I was advised this was a good sign and probably moving to the next stage of labour, don’t panic keep trying to drink and come in when contractions are worse

  • I should have been admitted there and then for fluids and antibiotics as I was probably puking because of the infection

  • Getting an infection because my waters had gone is just shit luck, that can’t be helped, its like getting a cold

  • When I was admitted at 11pm my blood pressure was very high, I had a temperature and my heart rate was very high, this is all signs of infection

  • I was 6cm dilated at this point, with contractions about every 1min 30 seconds and I was screaming for an epidural

  • Because of this I was told I would have to be monitored so they hooked me up to a monitor for Zak

  • They gave me a paracetamol drip and some fluids which brought my temperature and blood pressure back to down to normal

  • The hospital did not carry out a sepsis check until I had been there for 45 minutes, by which time my blood pressure and temperature had come down thanks to the drips

  • If they had done sepsis check on first admission, I would have been a red danger zone but because they waited, I was an amber so they decided to leave me and just keep me monitored

  • They took some blood from me and sent this off to check for signs of infection

  • They never checked the system for the blood results despite them being loaded and ready 1hr later

  • If they had got those results it would have showed how high my infection was and that I also had a kidney infection. I should have then been put straight on antibiotics and referred to a senior consultant

  • I never saw a doctor throughout my entire labour despite the warning signs

  • They lost contact with Zak’s heart rate for the last 20 minutes of me pushing. In actual fact my heart rate was so high that they thought it was Zak’s heart rate they were hearing (babies heart rates are always higher and typically 140 bpm)

Now that’s pretty shocking statistics to read and a bloody lot to get your head round. Tom asked the questions I didn’t want too, but wanted the answers to, like why they didn’t check me for sepsis on first admission – answer was they should have. Should they not have put me on antibiotics – yes, they should have. Then the big question – If they had done all the things the report implies, they should have would Zak have been born in the condition he was – the answer was shocking – no probably not. It was like having the life sucked out of me. They literally sat there, put their hands up and said they missed my sepsis and infection and if they had picked it up, Zak would have had more to fight with so although he might still have been born with meconium he probably would have started breathing of his own accord much quicker and not had any brain damage. I admired their honesty, but I certainly wasn’t expecting them to give me such a straight answer.

They did explain that following the report they had put into place the actions that HSIB had advised. One of them they had already addressed prior to the report and was already in place, which was taking more details on the phone. The biggest problem with that phone call I made at 7pm to say I was puking was that she didn’t really take any of my information, she didn’t ask if my waters had broken. If she did ask that then she probably would have suggested I come in to be checked and they could have picked up the infection then, because puking was a sign. There is now a form they have to complete when taking phone calls so they don’t miss any key information. They are also putting into place a better Sepsis checklist because I was a bit of a grey area, and retraining their staff that just because a patients blood pressure & temperature come down don’t assume all is ok, particularly if the heart rate is still high. They have put a better procedure in place so that things automatically have to be flagged higher up the chain and if any patient presents with even a chance of infection they have to be seen by senior obstetrician.

Now I want to make very clear here that I do not believe any of the mistakes made on the day were on purpose or malicious. I believe in the NHS and Swindon hospital and without their quick thinking when Zak was born, I would not have the baby that I do today. In spite of absolutely everything I would do it all again tomorrow! I would keep having babies and keep having them at Swindon hospital. They will never repeat the mistakes that happened that day, we all learned from it. In actual fact all my future pregnancies (hoping there are some!) I will be consultant led, not midwife led to ensure nothing happens like that.

For me there were also some positives to take from the meeting though. I thought when I first read the report that I had had a bad labour and perhaps I didn’t do as well as I had previously thought but they assured me that was not the case. For a first baby I was very low risk and breezed through pregnancy. Once I got into active labour about 9:30pm I progressed very quickly and in fact delivered Zak within 5 hours of being at hospital. I clearly grow big babies and deliver them with ease. I did it all with just gas & air and I thought I would have every drug under the sun. the doctor put a positive spin on it for me and pointed out that not only did I deliver such a big baby with ease, but I did it with sepsis, a kidney infection and no food or drink for 27 hours. She then said the female body was fascinating to those in medicine because we can cope with things most people couldn’t particularly in labour, something takes over us and we push through no matter what the odds, which is probably why I never felt poorly. I wasn’t looking for a pick me up or for her to fluff my ego, but I felt pretty heroic when she said that. Clearly women will always remain superior! She said she saw no reason why I would have trouble with future pregnancies and in actual fact future deliveries may well be easier because I would have full energy and be fully hydrated.

The meeting was inevitably emotional, and it made me feel a lot of things I didn’t expect and it took me a while to separate those emotions out. Ultimately, they fell into 3 categories – Tom, what happened to Zak and what happened to me. The shock of realising how poorly I was and yet I didn’t know and how much worse I could have been was too scary to think about. Understanding that Zak’s trauma could have been prevented was obviously the toughest pill to swallow. As his mum there is always going to be a part of me that feels guilty, that I let him down, it was my job to bring him into the world safely and I didn’t. And I know that sounds ridiculous but lets face it mum guilt is ridiculous. I felt angry and let down and hurt and frustrated that so many things were missed and if any one of them had been picked up then they could have changed the outcome and I could have had a normal birth and come home the same day, not waited 6 days to hold my baby. Then there was the emotion surrounding Tom and him being at the meeting and this is what took me by surprise. I don’t want to slate Tom, I’m trying to be the bigger person because I have to see him twice a week for the next 18 years but I obviously have a number of feelings regarding him and although I won’t go into detail I will say this. I cried in that meeting and he never asked if I was ok. At the end of the meeting I asked if he got what he wanted out of it and he said yes. He never asked me if I did. He went into that meeting with a statement he had prepared with his mum for the trust which was basically asking for compensation. The doctors and nurses obviously did not know we had separated and I did not tell them, so they spoke to us as a couple. They were really considerate of Tom and addressed how hard it is for the dads as they just have to stand there and watch and I was really pleased they did that because it must have been horrific for Tom to watch it all unfold; I was exhausted and when they were resuscitating Zak a midwife purposefully stood in my way so I couldn’t see what was going on but Tom could see it all. Then I got angry they were being so nice to him and I wanted to shout at them don’t be nice to him he walked out when Zak was 3 months old! But I didn’t. I just cried. Make of it what you will and there’s no right or wrong but it was in that meeting I realised then when we were in hospital with Zak Tom was a good parent and never left Zak’s side, but he wasn’t a husband. It was my parents who helped me dress and changed me, who encouraged me with breast feeding, who made sure I ate and got some fresh air. There was no support for me from Tom, and its taken me a year to work that out. My marriage was clearly over long before Tom left, and hindsight is a wonderful thing but it doesn’t make it any less painful. I’m not saying it was Tom’s fault or that he even did it on purpose but it makes me angry when I look back now and realise how much I put up with and how lonely I was. As tough as it was and as hard as the last year has been the best thing Tom ever did was leave me. Because of that I am stronger, because of that I have a bond with my child I may not have had and because of that I don’t give a shit and refuse to make any apologies for who I am or decisions I make.

This meeting also happened to fall in the same week as Zak’s first birthday, so it was already an emotional week. I was reliving his birth all over again without the meeting and seeing how far he had come and the things we had achieved was making it tough not to cry at every little thing. I was determined Zak’s birthday was going to be positive so I held it together and he had a wonderful day, but the day before I was a mess!

Its also probably worth noting that I will not be seeking compensation of any kind. I believe in the NHS and suing them will achieve nothing from my perspective, all it will do is cripple them further. Tom cannot sue them without me because its mine & Zak’s medical records and I have made it very clear to him too that I am not interested in pursuing it. I did not pay for a single bit of care from the moment I went into labour to the moment we were discharged. They provided accommodation, food vouchers, endless cups of tea and support, they milked me, they laughed with me, they cried with me, they encouraged and supported me, they sat with me all night long as I struggled to breast feed, they gave Zak 24hr life saving treatment for 10 days and I didn’t pay a single penny for it. Without their quick actions and making the decision to cool his body down to protect his brain from further injury, Zak would not have come as far as he has! And the care hasn’t stopped there it still continues now as Zak is under full paediatric care and will be closely monitored at least until he is 3.

So talking of Zak I’m sure some of you are curious as to how he is doing and the answer is fucking incredible! What happened to Zak is called Hypoxic Ischaemic encephalopathy or HIE for short which is a brain injury caused by an inadequate supply of oxygen to the brain and happens in every 1 in 1000 births. It has been proven that if a babys core body temparture is colled to 33c for 72 hours within 6 hours of birth this drastically reduced death and disability at 18 months and improves neurodevelopment; which is exactly what Zak had. The damage was caused to his central core which controls movement so could affect him in terms of speech, swallowing, sucking, walking and talking. They grade brain injury in 3 levels 3 being the worst, Zak is a 3. When we got his MRI results the specialists in Bristol explained to us that they expect Zak to have cerebral palsy, its not a case of if more a case of what. There is no way that Zak will walk away with nothing. Cerebal palsy can range in so many ways though from the guy on Britains got talent who can’t walk and talk to stiff muscles, or a limp or he might have a stutter or stammer. Either way we won’t know for sure until he is 2 or 3. At the moment he sees the physio every 3-4 months and the paediatrician every 6-9 months to monitor his milestones. He seems to be heading in the right direction for now as he is crawling, talking, trying to walk, can feed himself and is a very active child. Everyone milestone a baby achieves is amazing but for Zak its literally a miracle. The only concern they have at the moment is his right hand. He is very left handed dominant, he uses it for everything. He can use his right hand but the ligaments and fluidity of it aren’t as good as his left, he can’t use his pincer grip and often keeps it closed in a fist. He tends to tuck his first finger and thumb in a lot and because of this he can’t hold a bottle or cup very well and can’t yet use cutlery. This may be something he grows out of and is just a development thing, we have to remember he is only 15 months and still has a long way to go. In reality if all he walks away with is a right hand he doesn’t have full use of or gets stiff and he needs physio then we are bloody lucky. Those doctors are miracle workers! He is the happiest chattiest, smiliest kid, he loves being outdoors, he loves jumping in at swimming, he eats everything under the sun, he sleeps well and I could not be any prouder!

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