Couple's baby died after mum wrongly sent home from Salisbury Hospital

Jessica Read was 37 weeks into her second pregnancy when she reported feeling reduced fetal movements during a routine community antenatal appointment.  She was referred to the direct assessment unit at Salisbury District Hospital on September 21, 2021.

She underwent tests including bloods and a cardiotocograph (CTG), which monitors the baby’s heartbeat. 

Blood tests indicated pre-eclampsia – a type of high blood pressure that can lead to complications in mums and babies but Mrs Read was sent home before her abnormal blood test results were known and without a face-to-face review from an obstetrician being carried out.

If she had undergone an obstetric review, this would have provided an opportunity for the complexity of her pregnancy to be recognised and an immediate induction of labour would have been commenced.

Jessica Read was admitted to Salisbury District Hospital. (Image: Spencer Mulholland)

Later that evening, Mrs Read, 28, phoned the hospital and reported not having felt her baby move for two hours. The clinician documented a possible abruption and she was advised to call an ambulance as soon as possible.

When she arrived at the hospital, a CTG and ultrasound scan were carried out and no heartbeat was detected.

Mrs Read and her husband Ian, 37, were told that their baby daughter, Lillie, had died. An abruption of the placenta was confirmed at delivery.

Jessica and Ian Read are devastated. (Image: Lewis Brown Photography)

Following Lillie’s death, the couple instructed lawyers at Irwin Mitchell to investigate mum and baby’s care under the Salisbury NHS Foundation Trust.

It comes after the Trust, through NHS Resolution, admitted a breach of duty. Salisbury NHS admitted that a review, which would have indicated pre-eclampsia, wasn’t carried out.

If it had, the findings would then have led to Mrs Read being “recommended to undergo immediate induction of labour.”

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The Trust also admitted Mrs Read “should have received a direct review from the obstetrics team” and should have been advised to wait at the hospital for the results of her blood tests – which were abnormal.

It also stated that “on the balance of probabilities”, had Lillie been delivered earlier, she “would have survived.”

The Trust has apologised for the “shortcomings in the care” provided to Mrs Read.

The couple, who are parents to eight-year-old Isabelle and 13-month-old Fletcher, was "delighted" when they found out they were expecting another baby.

Isabelle was excited to become Lillie's big sister. (Image: Lewis Brown Photography)

Mrs Read said: “I knew something wasn’t right when I started feeling Lillie move less. But not for one minute did I expect to be told my baby girl had died.

“Not to return home from the hospital as a family of four was devastating.  For a long time, I kept hoping I would wake up and it wasn’t real.

“To then find out that more could have been done to save her is heart-breaking and something I don’t think I’ll ever get over.

“It’s been two years now since we lost Lillie and not a day goes by where we don’t think of her and how she would be growing up with Isabelle guiding her and having Fletcher to play with."

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Alice Fitzgerald Miller, the specialist medical negligence lawyer at Irwin Mitchell representing Mr and Mrs Read, said: “The past two years have been incredibly difficult for Jessica and Ian as they continue to try and come to terms with their tragic loss.

"Understandably, Jessica and Ian have struggled to overcome their ordeal especially while having so many concerns over the care provided prior to Lillie’s death.

“Whilst nothing can make up for their loss we’re pleased that we’ve at least been able to provide the couple with the answers and we now acknowledge the Trust’s admissions.

“However, sadly, through our work we see too many families left heartbroken as a result of maternity failings.

“It’s now vital that lessons are learned from this case to improve maternity safety.”

Chief nursing officer Judy Dyos, from Salisbury District Hospital, said: “We are deeply sorry for the tragic death of Lillie Read.  We worked with the healthcare investigation branch, have listened to their recommendations and have actioned the learnings in their report. These learnings have been shared with the whole maternity team.  We now have a more robust process to follow-up results in our day assessment unit and to ensure senior review of complex patients.

"Our mission is to ensure the safety of women and babies in our care and this is the goal we strive for everyday.”