A MOTHER-TO-BE whose daughter died a month after being born at the Hospital was in “distressing” and “horrible” pain shortly before she gave birth, a midwife has told an inquest.
Parents Dominic and Ewelina Clyde-Smith lost their daughter Amelia 33 days after she was born in August 2018, and more than five years later an inquest into her death resumed yesterday to consider the circumstances and determine how she died.
Senior health officials previously apologised to the parents and admitted Amelia’s death was “probably” avoidable, following an investigation by the Royal College of Obstetricians and Gynaecologists which found there had been “missed opportunities”.
During yesterday’s inquest, midwife Tambu Muoni, who worked in the maternity unit at the Hospital since 2007, gave evidence about the night shift she had worked on Saturday 18 August, when Mrs Clyde-Smith was in her care.
Ms Muoni said: “I don’t think I had seen that level of pain, ever, it was distressing and horrible.”
The inquest heard that Mrs Clyde-Smith experienced a normal pregnancy until her waters broke around a fortnight before her due date, prompting her to come to the Hospital with her husband.
Staff started the process of inducing Mrs Clyde-Smith into labour on the afternoon she was admitted, however she told the inquest that she had experienced increasing levels of pain during the following night.
She had been told by staff at around midnight that she was not likely to go into labour for 24 hours, but this happened within a few hours, by which time she was doubled up with “horrific” pain.
Attempts to administer an epidural injection were initially unsuccessful as a result of the strong contractions Mrs Clyde-Smith was experiencing, but the injection was eventually given after her husband helped restrain her.
The inquest heard that Ms Muoni and other staff in the labour ward did not escalate the treatment of Mrs Clyde-Smith and that Amelia, who suffered suspected brain damage, had been transferred by air around ten hours after being delivered in order to receive specialist care in the south of England.
Mrs Clyde-Smith said she had outlined a series of concerns regarding her care in a letter to the Deputy Viscount, including not being seen by a doctor, going long periods without care from a midwife, the failure of staff to act on high readings from the cardiotocography scanner which measured Amelia’s heart rate and the failure to keep the placenta for analysis.
“It felt like no-one had Amelia’s best interests at heart that night,” she said.
The inquest heard that there had been difficulties on the labour ward the night before Mrs Clyde-Smith was admitted to the Hospital. Details were not given, but Ms Muoni said that members of the night shift team had been shocked by what had happened, and that a manager asked her not to mention the incident in her initial statement to investigators.
Amelia’s death led to an investigation by the Royal College of Obstetricians and Gynaecologists, who found that there were “missed opportunities with management of maternal observations” after complications with the birth were recognised and that there was “an absence of a proper escalation policy” once things started to go wrong.
Chief nurse Rose Naylor and medical director John McInerney wrote to Mr and Mrs Clyde-Smith in 2019 to offer an apology, saying that although they could not say whether her death was “inevitable”, adding “we probably could have avoided it, and for that we are deeply sorry”.
