Our son, his story.
This is a blog that I knew I wanted to write for a while, I have had so many thoughts and feelings in my head that I knew I needed to get out onto paper (or screen!) yet it has never felt like the right time to do so for one reason or another. It’s going to be a long one, full of raw, honest emotions and probably a strong undertone of anger and sarcasm throughout, so strap in.
I found out I was pregnant in November 2019, after a very uneventful and calm, low risk pregnancy Covid hit as I went into my third trimester, the plan was to always have Clay at Bassetlaw hospital, but then when Covid hit and the world went into melt down, Bassetlaw maternity services closed which meant our next option was Doncaster, which for multiple reasons wasn't our preferred choice. So, I started to research into home birth, as my pregnancy was low risk and my hypnobirthing course had taught me 'mind over matter' and made me believe a few positive affirmations were all that I needed (lol. more on my thoughts around hypnobirthing another time). We came to the decision to plan for a home birth, it meant both Dan (my husband) and my mum could be with me which was my preferred choice, and we wouldn't have any long stays in hospital with Dan not being able to visit. There were some concerns about Clay being a large baby on growth scans, but we were told it was safe to deliver at home as long as we had a low threshold for transferring into hospital if any problems arose.
In the evening of Monday 13th July 2020 my contractions had started to become regular, and throughout the night they started to become closer together and by 8am Tuesday morning my waters broke. By 10am my contractions were every 2-3 minutes apart and very intense. However, I was still only 2cm dilated (I was 2cm dilated on the morning of Monday 13th). A few more hours went by, I got into the birthing pool and after a while our midwife asked me to get out to examine me, to my utter disbelief I was still only 2cm dilated at 2pm. I was exhausted, confused and deflated as to why I was contracting but not dilating, due to me wanting some additional pain relief and my midwives’ recommendations we transferred into Doncaster hospital where I was given an epidural (thank f$£k!!) the afternoon passed in a blur of napping, some meaningless chatter and not much else.
By around 7pm, I was checked again and found to be fully dilated and given a 'passive hour' to allow Clay to come down the birth canal more before I started pushing. I can remember excitedly texting my best friends to say to wait up as baby would be here before they went to bed. To this day I daren't go back and read those final few messages before our world exploded. I started pushing and was pushing for an hour and a half when the senior midwife came to see me to let me know pushing was capped at 2 hours for your first baby, she said she could get the doctor to come and see me for intervention. I was so exhausted, I'd be sick all down myself, awake since 4am the previous morning, but our midwife encouraged us to keep pushing. Unbeknown to us at the time, Clay's head was still at spines, where it had been from 2pm when I arrived at hospital and his heart rate had been high (tachycardia) from 9pm onwards, potentially even earlier.
Under the midwives advice, I carried on pushing for another 15 minutes before the doctor came to see us and explained she thought Clay needed some help getting out. She originally said she was going to try with a ventouse but then later came back in the room to tell us she had looked at Clay's notes and as he was measuring on the 90th percentile, she was going to use forceps instead, in the delivery room we were in. Pre-covid, forceps had been my idea of a nightmare they were the thing that I definitely did not want, I would rather have a C-section, but because of Covid which meant a long hospital stay with no visitation allowed from Dan if I had a C-section, plus being told that was the best way of Clay being born (and to be honest, not knowing that I could say no) we let her go ahead.
2 pulls later with the forceps, Clay hadn't moved down. Dan saw both pulls and the second was using all the muscles in her arm to the extent that they were bulging out. She abandoned the third attempt and informed us she was going to ring the consultant, but she wanted to take me for a C-section. At this stage I was upset but exhausted and I just wanted the labour to be over. About 40 minutes later I was in theatre, watching Clay's heart rate on the monitor as they put my spinal block in, I can remember seeing his heart rate being around 185-190 and thinking 'god that's high' but nobody in the room seemed to notice, everybody was calm and having a laugh and joke. Little did I know that was the last time I would ever see Clay's heartbeat.
The C-section started and Clay was born, but he didn't cry. I told myself in my head not to worry that this can happen, he was blue and floppy and was taken straight to the resuscitation table. The anaesthetist came over to tell us he was ok; he just needed some help. Two thoughts flooded my mind 1) he was a boy (Dan was supposed to be telling me the gender) 2) ok, good he's ok. It quickly became apparent that wasn't the case, crash calls were put out, people were running in, shouting, too many people surrounding such a tiny being. At some point I heard and saw him gasp, relief flooded through me, "surely this means he is ok", then 10 minutes passed. At this point, Dan and I looked at each other and said this doesn't look good. 23 minutes after he was born, the paediatrician turned around and told us Clay had not made it. He was dead.
Our baby boy, who I had only been watching his heartbeat 30 minutes ago, was placed into our arms with a tube in his throat and tubes coming out of his tiny body. He was so warm, so life like, yet lifeless. He was and is the most beautiful baby I have ever set my eyes on, he had his dads chin, my nose, and the chunkiest thighs I've seen. He had wreck-it Ralph sized hands and the Wankiewicz traditional big toe. He weighed the same as me when I was born (9lbs 4) and only 4cm shorter in length, he was the perfect combination of the both of us and my heart aches every day for not knowing how he would look now.
The hospital said they didn't know what had happened, that they had never seen anything like this ever happen before. As Clay had been born alive and died shortly afterwards his death was reported to the coroner, so he was sent to Sheffield Children's Hospital for his post-mortem. We also had a HSIB (Health and safety investigation branch) investigation started which we were interviewed for in August 2020, one of Dan's most vivid memories from my labour was witnessing the forceps attempt, he let HSIB know that he felt the force used from the first pull to the second pull were completely different with the second pull using a lot more force. Aside from Clay dying, the wait for his post-mortem results was the most torturous thing we have ever had to go through.
In December 2020 we received the post-mortem results, after being told time and time again 'it could come back with nothing'. One of the midwives had even mentioned it could be his heart. But in our gut we felt like the hospital were at fault, things cannot go that wrong that quickly for no reason. And we were right. Clay's cause of death came back as 'skull fractures in context of instrumental delivery'. We later found out Clay had suffered 5 skull fractures of varying degrees, of which 2 of them were in a curvilinear nature on the right and left sides of his skull, in our eyes these cannot be from anything but the forceps.
After Clay's post-mortem results, the very little and shoddy communication from Doncaster hospital pretty much stopped in its entirety. I mean 2 visits from a bereavement midwife who tells you 'I know how you feel, my dad died last year' (she was probably 60-65) followed by long, painful silences and probably around 3 phone calls is not the best support to start with. To be fair to Doncaster, I did receive one phone call from the governance midwife 3 weeks after receiving his post-mortem results (which joyfully coincided with the day after I had miscarried in December) which basically went along the lines of 'maybe something was wrong with his skull' and 'oh yeah I can see on your notes you had a miscarriage yesterday, I'm sorry'. Yeah... pretty shit, all in all. After that we heard pretty much nothing else.
In May 2021 we were approached by BBC panorama as they had been carrying out investigations into hospital reports that had never been made public, one of these was into Doncaster and Bassetlaw Trust maternity services that were done in 2016. Heartbreakingly, reading through the report highlighted several issues we had raised in Clay's care, and it couldn't have been a coincidence that issues we had raised were also issued raised in a report 5 years prior. We felt compelled to stand up and speak out about this evidentially underperforming, egotistic hospital. You can read the original BBC article here. Surprise Surprise when we received 2 letters through the post a month later suddenly inviting us in to discuss all the things that had changed and put in place since both 2016 and Clays death. It was too little too late I'm afraid.
By this point we had also received the statements from the witnesses that were due to give evidence at Clay's inquest and from reading some of the statements it was evident Doncaster felt they had done nothing wrong. So let’s take a short interlude to recap, Clay; a healthy, full term baby, had miraculously passed away and sustain 5 skull fractures all on his own had he?? honestly if anybody from that hospital thinks that they really should not be in that profession at all, it worries me to know there's health care professionals out there that are so stuck in their ways that they can't see a bus when it hits them in the face. Whether they truly believe they did nothing wrong, they just can’t bring themselves to admit that their actions and decisions weren't the right ones or Doncaster's legal time have pushed them to write their statements in that way is another matter.
This is not me bashing all medical professional by any means. I'm sure even Doncaster does do some things right, I think the NHS is brilliant in many ways, and I'm sure most of the staff are too, but just because the NHS does so much good, doesn't mean we should roll over and turn a blind eye when they fuck up, especially when they fuck up and then claim they did nothing wrong. That's the scariest and most worrying thing of all. I don't know if hospitals understand that if they have been involved in a baby's death, if they just held their hands up and admitted they had done wrong and then laid out what they were going to do in order for it never to happen again, that's all that we as bereaved parents can ask for, nothing will ever give us what we truly want, which is our baby in our arms but the best and honourable thing a hospital can do is own up to their mistakes, identify what they can do to improve and implement them straight away.
Doncaster, unfortunately in our eyes, have not done that. They have put their egos and reputation first and have denied, deflected, and defended their horrendous actions. They tried to go down the route of saying I wanted to carry on pushing which is why they didn't intervene sooner. The damage that has done to me over the past 14 months is irreversible, as a mother you are always going back over what happened and trying to stop it in your head, change decisions so you can change the outcome, but to feel like somebody is putting blame onto you is emotionally and mentally draining, not to mention unfair and cruel.
Clay's inquest is up there with the most mentally and physically draining days since Clay died. To be in a court room with a group of people, some of which decisions and actions contributed to the death of your son is indescribable. To sit through evidence and learn in more depth how preventable Clay's death was is utterly heart breaking. We always knew Clay shouldn't have died, but to hear it in full, point after point, makes it all so much more infuriating. The Trusts barrister was also an absolute cock womble. He looked like he stepped out of a 1980's crime TV show, he was unprepared (literally didn't have his files etc for when the inquest started), unprofessional and downright rude, at no point did he say he was sorry for our loss to our faces, and he kept laughing and making shit jokes to his colleagues (you sit directly next to their legal team at an inquest which is just a nice little cherry on top of the absolute shit cake you are in).
One of my most memorable moments in the inquest is when the coroner asked one of the midwives what had changed since Clay's death on the ward, to which she replied 'nothing'. For a moment I felt like I couldn't breathe, did I just hear her correctly?? here we were sitting nearly 14 months on from Clays death and being told nothing had changed? it was like a kick in the teeth. Clay's death should never have happened, but all you want as a parent is to know the chances of this happening to another family are significantly reduced, so to hear nothing had changed just made me feel like Clay had died in vain. It's one of the reasons I'm writing this blog, I cannot let Clay die in vain, we cannot let Doncaster hospital brush this under the carpet and not change their ways. The consequences of them doing that could be abysmal. We will not be silenced and told we have got it wrong. Healthy, full-term babies do not just die in labour for no reason, it is because of the wrong decisions of medical staff, systematic hospital failures or just down right negligence.
The Coroner’s conclusion was warmly welcomed by Dan and I, and our families. She agreed with us on all the points we had raised and issued Doncaster with a prevention of further deaths order, it seems a leaflet on a notice board and a training course that the staff involved haven't even been on isn't enough improvements in 14 months surprisingly. For nearly 14 months we were told from the hospital they could find nothing wrong in what they did, when you are told something so many times you start to question your own recollection, wondering whether you remember rightly or 'are just trying to find somebody to blame', but it’s not that. When your baby dies due to failures in care, you aren't just trying to 'find somebody to blame' to make yourselves feel better, you are fighting for change and accountability, you don't want your baby’s death to be in vain and you just want them to acknowledge their failings and do better. It's really not that much to ask for after they have not only robbed you of a life with your baby but changed your lives and you as a person forever. It’s not just Dan and I either. My parents have lost their and must longed for first grandchild, Dan’s parents have lost a grandchild, aunties and uncles have lost a nephew, our niece and nephew have lost a cousin to make a lifetime of memories with. The loss runs so much deeper.
One thing I would definitely recommend for anybody going through a Coroners inquest with similar experiences to us is to get a solicitor and a barrister. Our legal team have been nothing short of amazing since we first spoke to them after receiving Clay's post-mortem results, I truly do not know what we would have done without them. The support and understanding they have given us, whilst championing for Clay and us as a family is invaluable. Going into the inquest we didn't know what to expect, but 2 full days of witnesses giving evidence, we would never have been able to sit and ask them questions, yet the ones our barrister asked felt like they were tumbling out of our heads right into his mouth. No, you do not 'need' a legal team for an inquest, but in cases like Clay's for us it has been more than just a need, it has been a necessity. To our legal team, I know you will be reading this blog, so thank you from the bottom of our hearts. And if you do find yourselves in the horrendous position we are in and don't know where to turn, I am more than happy to recommend the firm we used so please feel free to drop me a message.
If you are reading this nodding along because you yourself have been told "we've never seen this happen before" and the hospital are dodging your questions quicker than James Bond dodges a bullet I want to let you know that you are not alone. You are not exaggerating, you are not an annoyance because you won’t settle for their half-arsed answers, you are not 'kicking up a fuss' and most importantly, it is not your fault. There is no hierarchy to baby loss, all baby loss is absolutely shit. But when your baby dies because of others decisions and actions it adds another layer to grief that is hard to explain and understand. There's no comforting answers or explanations, because behind every comment, every 'answer' is the knowledge that if things had been done properly, your baby would be in your arms.
Clay will always be our first born, much loved and forever missed baby boy. He was taken from us in a way you'd only read in a horror story. But he made us parents, he has shown us how much you can love another human being even if you only get to physically meet them for moments. He is the reason we will continue to pursue Doncaster and fight for change. He gives us the strength to carry on and the bravery to fight. We are forever proud of our amazing little boy. He fought so hard to stay with us, but that decision was taken out of our hands.
We love you to the moon and back Clay.