Human Interest

Twin babies die due to ‘system failures’ that accidentally canceled vital ultrasound

premature, prematurely

An investigation has concluded that “lapses in care” resulted in the preterm delivery and deaths of twin newborns.

Amber Lincoln and her partner Darren are parents to a 13-year-old daughter and were “overjoyed” to learn in 2022 that they were expecting twins, but since Amber had previously undergone a procedure that left her at risk of preterm labor, she was supposed to undergo extra scans at a specialist clinic at Lewisham and Greenwich NHS Trust, which runs Queen Elizabeth Hospital.

She had undergone a loop electrosurgical excision procedure (LLETZ), a common way to treat precancerous changes in the cervix, in 2020. This left her at risk of miscarrying. She miscarried two babies at about six weeks in September and December 2021. After learning they were expecting again in July 2022, a scan at nine weeks found she was having twins.

What went wrong

Amber was then supposed to be booked for specialist scans. One of those was a cervical scan at 16 weeks, but the appointment was never scheduled after an IT system error canceled the entry that should have alerted the system and staff that an appointment needed to be made.

At 22 weeks’ pregnant, six weeks after she should have had the vital scan, Amber was admitted to Queen Elizabeth Hospital, and her twins, Anaya and Mael, were born the following day on November 23. They died shortly after birth. According to Hampshire Live, daughter Anaya was delivered breech at around 12:20 p.m., and son Mael was born 90 minutes later. Anaya died before Mael’s birth.

After losing their babies, Amber and Darren asked attorneys who specialize in medical neglect to investigate. A “Red Incident Investigation” report by the Trust found that “lapses in care” led to the premature birth and deaths of the babies.

“This is a tragic case which has left Amber and Darren devastated,” said Hannah Delahoyde, the medical negligence attorney who is representing the couple. “While the Trust’s investigation report has identified worrying issues in the family’s care, understandably Amber and Darren continue to have a number of questions about the events that unfolded. While nothing can make up for their loss, we’re now determined to provide them with all of the answers they deserve.”

Amber explained, “We wanted everything in place to make my pregnancy run as smoothly as it could. The baby scans didn’t show any issues, but it felt like my concerns and the concerns doctors had previously raised connected to my LLETZ weren’t fully understood or listened to. I felt that I went out of my way to raise these at the various appointments I had but it still felt like nothing was really happening and I had to always remind the medical staff or chase up for a cervical scan appointment.”

She said that when she began to experience back pain and contractions, she knew something was wrong. She called her babies’ births “a traumatic experience.”

“The doctors in the delivery suite did everything they could to save them but sadly they couldn’t,” she explained. “It’s almost impossible to find the words to describe what it was like knowing Anaya had died before Mael was born.”

The Trust apologized “for the lapses in care that resulted” in Amber losing the babies. It also said that “the care pathways and system failures that contributed to their loss fall below our expected standards of care and we are very sorry that this happened.”

More details

Due to her history, Amber was supposed to be referred to a pre-term birth clinic but an IT error allowed a medic to select the wrong option to record the scan results, which then led to a cancellation of an entry in the system indicating that a cervical scan was needed. At a follow-up appointment, she was not referred to the specialist clinic as she should have been. A month later, medical staff failed to refer her for a second time.

On October 3, she called the midwife team to express her concerns that she had yet to undergo the cervical scan she knew she needed. She was then supposed to have a scan at 16 weeks, but there were no appointments available. After more issues, she had a scan at 17 weeks on October 20, but the results would not be reviewed until November 2. That appointment was canceled and rebooked for November 30. Amber never made it to that appointment. She went into preterm labor on November 22.

“The last few months and trying to come to terms with the events that happened have been awful,” said Amber. “Sometimes I wish I had pushed even harder to be heard by the medical staff, but I know that I couldn’t have done or said anything more than I did. We loved our tiny dancers, our hearts are broken that we can’t see them. We’re grieving the future that they would have had if they were with us, they’re terribly missed.”

A spokesperson for the Trust said, “We are deeply sorry and offer our sincerest condolences to Ms Lincoln and her partner for the tragic loss of their babies. We carried out a full investigation and have made changes to our processes as a result.”

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