Barnsley Hospital apologises over childbirth heartbeat failings

BBC Emily BarleyBBC
Emily Barley says baby Beatrice died after several opportunities for staff to accurately monitor her heartbeat

A hospital has apologised to the mother of a baby who died after staff failed to correctly monitor the child's heartbeat during birth.

Emily Barley's baby, Beatrice, died at Barnsley Hospital after staff mistakenly checked the mother's heart rate instead of the baby's.

Earlier consistent monitoring of Beatrice's heart "may have affected the baby's outcome", a report concluded.

The hospital said it was implementing the report's eight recommendations.

A hospital spokesperson said it "entirely accepted" the findings of the Healthcare Safety Investigation Branch (HSIB).

Ms Barley, 33, from Rotherham, South Yorkshire, said it felt "like my whole world died" following Beatrice's death.

Baby Beatrice's hand and feet prints
Baby Beatrice died at Barnsley Hospital on 20 May 2022

She said she had gone into labour on 20 May, with the maternity ward "fully staffed and quiet" at the time.

Ms Barley said midwives thought the cardiotocography (CTG) baby heartbeat monitor was broken when they started to struggle to find Beatrice's heartbeat.

Staff failed to act when the machine showed a problem and they were "falsely reassured" after mistaking her heartbeat for Beatrice's, she said.

"They didn't act when monitoring showed when Beatrice was in trouble. They made a mistake, thinking it was Beatrice's heartbeat, when they were actually picking up mine," she said.

"When they couldn't find Beatrice's heartbeat at all, they faffed around."

The HSIB report identified opportunities where Ms Barley's case could have been escalated sooner, including when an abnormal foetal heart reading was first detected.

When staff mistakenly monitored Ms Barley's heartbeat instead of the baby, the reading should have been confirmed with other methods, the report added.

"Earlier consistent continuous monitoring of the baby's heart rate may have affected the baby's outcome," it stated.

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HSIB safety recommendations included:

  • When an 'abnormal' CTG occurs with no previous monitoring history, and the duration of the concerning features is unknown, urgent escalation takes place
  • Any CTG review is considered alongside previous CTGs to allow staff to consider any change in a baby's heart rate patterns
  • Ensure that a foetal heart rate is confirmed before a CTG is started
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Ms Barley said Beatrice's death had left her feeling "robbed".

"There's everything, not just me but everything, Beatrice was supposed to have," she said.

"It feels like a physical pain. It weighs in my arms and my legs. It makes everything really, really hard just to function."

Using Freedom of Information requests, Ms Barley said she had since discovered there had been 12 other maternity investigations at the hospital between 2019-22, resulting in 41 safety recommendations.

"I think that phrase, 'lessons will be learned' is used a lot, but it needs to happen now because these babies, my baby, are so precious," she said.

Google Barnsley HospitalGoogle
Barnsley Hospital says it is implementing the report's recommendations and staff have met Ms Barley to apologise

Dr Richard Jenkins, Barnsley Hospital's chief executive said: "We are deeply sorry for the loss of Beatrice and we have met with Emily to apologise.

"We immediately recognised this tragic event should not have happened and we reported it to HSIB.

"We have fully cooperated with their independent investigation and we entirely accept the findings and the recommendations which we are now implementing."

Referring to the other maternity investigations at the hospital, Dr Jenkins added: "Each case is unique and provides specific and distinct learning points that allow the service to make progressive improvements."

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