Closed Ranks

I rang and emailed the hospital several times over the next couple of days, just to be told that people would ring me back but never did and the emails went unacknowledged.  The list of questions was now growing and we were getting enormously frustrated.  We concluded that the hospital had closed ranks and were not prepared to discuss anything with us, right from the point of Amanda’s waters breaking to Mia's death 54 hours later, as far as they were concerned we were a closed book.  We were unhappy with the treatment, we felt let down and invisible.

Eventually the PA did ring my office to tell me that Mrs Nishtar was prepared to meet with us but on an unofficial basis.  I said that I was not prepared to do that and any meeting would have to be official and documented.  The PA went on to say that “I had to understand that Mrs Nishtar is a very caring but busy woman and our daughter tragically passed away through natural causes and I was just getting obsessed with trying to find blame” – I wrote that phrase down as I was so appalled by her attitude towards us.  I told her to forget about any unofficial meeting or conversation.  I didn’t know if I would regret that over time but I felt that was the right thing to do.  This was a period when Amanda and I although incredibly close also felt so isolated and alone, nobody knew what to say to us and would imagine in many cases were perhaps uncomfortable being around us.

This was the point when we realised that whatever answers we were to get in the future we would have to fight for them, possibly upset healthcare professionals, we would need to develop a thick skin.  That little girl was never going to be forgotten and we would give a purpose to her very short life and we vowed we would not be silenced.  The days at this point were very bleak, very little to look forward to and always worrying about the state of mind of Amanda and the children and always forgetting to look after myself.  Professionally, my work was probably suffering, nobody knew how to approach me.  Some would try, others would be of an old school of “these things happen”.  I was getting increasingly frustrated with others and getting irate over small things, triviality which in the grand scale of things were unimportant like someone being told that they were needed in the office after 5pm.  We were locked inside our own little bubble, forever investigating things, asking questions to ourselves because we did not have any real answers – the main problem was that the hospital would not communicate, we had a burning desire to find out why we were told that Chorioamnionitis is not caused by a Group B Strep infection and several other key things:

We constructed a list of 3 critical items that in our view had to be explained by the hospital as to why they did not trigger further action:

• Amanda’s waters broke at 2pm on Saturday 11^th January and had not delivered over 48 hours later (risk to baby x 3)


• Amanda’s waters broke before 37 weeks (risk to baby x 3)


• Amanda’s temperature was well above 37.5C (it got as high as 39.1C) - (risk to baby x 4)

Any one of the above should have necessitated for Intravenous antibiotics to have been given and 2 other additional questions that were not directly life critical were unanswered.

• Why was she not scanned until nearly 48 hours after being admitted into hospital?


• Where were the observation notes from when Amanda was checked over by the nurse in the early hours of Sunday 12^th January?

To be fair, we weren’t sure what we were going to do with our list but it was eating away at us.  In April 2014, three months after her death we did put the questions to the hospital again and received a phone call from Nishtar’s PA to state that nothing had changed and no re-review of the labour was planned. She went on to state that there was no record of any observation notes stating that Amanda was assessed during the early hours of the Sunday and no notes of her temperature going above 37.5C.  She was effectively accusing us of lying to try and force a review.

In hindsight, as I review some of these notes made several years before we did have a clear case to pursue because the Royal College of Obstetricians and Gynaecologists (RCOG) first recommended a prevention strategy against Group B Strep back in 2003 and various key factors were introduced including the first 3 points above.  They meant that risk factors were 36 times higher (3 x 3 x 4) than if her waters had broken within the past 18 hours, her temperature was less than 37.5C and she was full-term.  If it was known whether Amanda carried Group B Strep when delivering any of her previous children that risk rose to 360 times higher and if it was known Amanda was carrying Group B Strep in her urine at the time of her waters breaking the risk to her and the baby increased to 1,440 – those are numbers that we will never know but given that this was her 5^th labour, one of her previous 4 statistically meant that she was likely to be a GBS carrier during one of those previous labours.  But we can surmise that Amanda was carrying GBS at the time of entering labour therefore the risk was at least 144 times more than an uncomplicated full-term pregnancy.

It is only now, several years later that Amanda and I are starting to appreciate the full scale and horror of what happened with Mia from a patient and baby safety perspective right from the moment that Amanda’s waters broke right through to the presentation of the pathology results.


It just left one big question.  How the hell did all of the above not force a trigger in the systems, whether computerised or manual?