A tragic case at a British hospital has reignited debate over patient safety in maternity care after a woman lost her baby just days before giving birth. An investigation linked the incident to problems with the functioning of the device monitoring the baby’s heart rate.
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Thirty-two-year-old Bethany Sowerby went to James Cook University Hospital in Middlesbrough during the 38th week of her pregnancy after noticing that her daughter, Hattie, was moving less than usual.
Following initial assessments, doctors placed her on a cardiotocography monitor, or CTG, to track the fetal heart rate and uterine activity. While staff were also attending to other patients, Bethany noticed about 30 minutes later that the device’s paper had jammed and the recording was not being made correctly.
When staff checked the monitor, the baby’s heart rate was found to be below normal limits. Doctors and midwives responded immediately, but they could no longer find the baby’s heartbeat.
A subsequent ultrasound showed that the situation was critical and that the baby needed to be delivered urgently. A second check confirmed that the baby’s heart had stopped beating. Hattie was pronounced dead on 16 May 2023 at 9:43 p.m.
A report from an independent investigation found that the monitor’s alarm had activated when the paper jammed, but it was not heard because the device had been muted.
The data printed by the monitor also showed a pathological pattern in the fetal heart rate. This signal was not detected until after the baby’s death.
Post-mortem examination results showed that Hattie had suffered a lack of oxygen before she died. The following morning, Bethany gave birth to her stillborn daughter.
Following the incident, Bethany was diagnosed with post-traumatic stress disorder, PTSD. She has chosen to share her story publicly during Baby Loss Awareness Week, hoping that similar cases can be prevented.
The family is calling for safety protocols to be reviewed and improved, as well as for the way medical devices are checked to be strengthened, especially when they provide signals of dangerous changes in the baby’s condition.
The hospital and the institution responsible for health services have expressed their condolences to the family but declined to provide further comment because of ongoing legal proceedings.
The incident has raised serious concerns about the need for continuous monitoring of monitoring equipment and for staff to respond immediately to signals that could indicate a risk to the life of the mother or baby.
