Baby dies after heart monitor suffers paper jam

Mum Bethany Sowerby was left devastated by her baby’s death (Picture: Getty Images Europe) A baby was delivered stillborn after staff failed to notice a paper jam on a monitoring machine because its alarm was set to silent, an inquiry has found.

Bethany Sowerby, 32, was taken to the James Cook University Hospital in Middlesbrough after becoming worried about her unborn baby Hattie’s movements.

Doctors had been monitoring the baby’s heart rate but had not noticed a paper jam in the machine.

An initial assessment had found the baby’s heartbeat to be normal, before which she was connected to a CTG monitor.

It was then that the jam occurred, but staff did not notice initially.

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Mrs Sowerby then alerted staff, who were attending to other babies on the ward, to the paper jam.

They then found Hattie’s heart rate was below the normal range.

Doctors then decided the baby needed to be delivered immediately by emergency C-section after an ultrasound scan found her heart rate had dramatically slowed.

An independent inquiry by the Healthcare Safety Investigation Branch (HSIB) found that the alarm for the electronic monitoring machine to indicate the paper jam was not triggered because it was set to silent.

A re-print of Hattie’s heart rate showed it to be pathological but this was not recognised before she died at 9.43pm on May 16, 2023.

The probe concluded that failing to recognise the dangerous reading which showed Hattie was in distress likely contributed to her death.

Mrs Sowerby has since suffered from post-traumatic stress disorder and is undergoing therapy and taking medication following the loss of her daughter.

The mother from Redcar, North Yorkshire, recalled her baby feeling ‘cold’ as she held her.

She said: ‘Holding her for the first time also became the last time. She was so cold, I’ll never forget what I felt in that moment. It broke me.

‘When I came home after she passed, I couldn’t bear to look at anything – the presents people had bought her, the clothes she was meant to wear and the room we’d decorated for her.’

She added: ‘Our little Hattie would have turned three this spring and we’d have celebrated so many milestones by now, her first birthday, first words and first steps.

‘But the reality is that I never got to take our daughter home from hospital.

‘I carried her for nine months and we couldn’t wait to meet her and introduce her to her sisters.

‘It was supposed to be one of the happiest days of my life, just like it had been with my other children, but it became the most traumatic thing I’ve ever experienced.’

Bethany, who has three other children – Ella, 12, Olivia, nine, and Oakley, two, with partner Matthew, 33 – added: ‘Matthew and my children keep me going. I want to be the best mum I can be for my kids but there are days when the weight of losing Hattie feels overwhelming.

‘Living with that grief while trying to be present for my family is something I struggle with every day.

‘Not a day goes by when I don’t think about what might have been and everything Hattie has missed.

‘I feel I have to speak out so this doesn’t happen to another mum or baby.’

Mrs Sowerby had sought advice during her pregnancy due to concerns about Hattie’s movements, and plans had been made to induce labour at 39 weeks due to the recurring issues.

Katy Daws, specialist medical negligence lawyer at Irwin Mitchell representing Bethany, said: ‘Bethany’s maternity experience was extremely traumatic and the loss of Hattie continues to have a profound impact on her life.

‘Both her and Matthew are still struggling to come to terms with their heartbreaking loss at what should have been a time of celebration.

‘Our priority is now ensuring Bethany receives the support and specialist treatment she needs.

‘In the meantime, the findings of the investigation report are deeply concerning and identify a number of issues. It’s vital that lessons are learned to improve maternity safety for other families.’

This week is Baby Loss Awareness Week, which runs every year from October 9 to 15.

A spokesperson for South Tees Hospitals NHS Foundation Trust said: ‘The trust wishes to extend its sincere condolences to Bethany and her family for the loss of Hattie.

‘The matter is in the hands of the parties’ lawyers, and the trust is therefore unable to comment further at this time.’

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