Sarah and Andrew Conroy are calling for improved maternity safety after their son tragically died in hospital
A “miracle” baby died in his father’s arms after doctors delayed a blood transfusion by three hours. The measure could have saved baby Kit’s life who was born in a poor condition at University Hospital Lewisham in March 2021.
Kit needed to be resuscitated after his mum Sarah Conroy suffered a serious bleed, known as an antepartum haemorrhage – where the placenta separates from the womb – during labour. However, instead of giving Kit an emergency blood transfusion during his resuscitation, medics at London’s University Hospital Lewisham did not administer blood until he was three-hours-old.
It was the third time Sarah had suffered significant bleeding – having previously been admitted to the hospital at 36 weeks and three days into her pregnancy. She had lost around 300 millilitres of blood at home and was diagnosed with a major antepartum haemorrhage. The cause of the antepartum haemorrhage was not identified and she was discharged.
At 38 weeks and four days, Sarah suffered a second episode of bleeding and again attended the hospital. She was offered induction of labour at 39 weeks of her pregnancy.
At around 1.12pm on March 13, 2021 Sarah thought her waters had broken, but she had actually suffered a significant bleed. A decision was made to deliver Kit by emergency caesarean. Kit, who was starved of oxygen during delivery, was delivered at 1.28pm.
He took his first breath at nearly 17-minutes-old and did not start receiving blood until just after 4.30pm. However, his condition deteriorated and he died around six hours old in his dad Andrew’s arms.
During the bleed and subsequent surgery Sarah lost around three-and-a-half pints of blood.
Lewisham and Greenwich NHS Trust later admitted breaches of duty in that an emergency blood transfusion was needed, there was a delay in transfusing neonatal blood and the volume of blood given to Kit was less than required.
However, the Trust stated that had Kit received a transfusion during resuscitation he would have survived with significant brain injury and if the blood transfusion had taken place after resuscitation he would have died. The Trust said that it was not liable for his death.
Sarah and Andrew Conroy, along with medical negligence lawyers Irwin Mitchell, followed up with further legal submissions. Before the case got to court, the Trust agreed an undisclosed out-of-court settlement.
The couple have since had two babies – Cooper aged two and Jude who is eight months old- but are now campaigning for maternity care to improve nationally.
‘The day Kit was born should have been the happiest of our lives but it turned to absolute despair’
“We’d called Kit our little miracle,” Sarah said. “I’d had surgery to remove fibroids and despite years of trying it felt like we were never going to have any joy. We’d started to look into IVF and were due to have an initial appointment, however, the day before that meeting I found out I was expecting.
“We were overjoyed that our dream of having a baby was coming true. We attended all the midwife and ante-natal appointments and scans and everything was fine.
“Then one day I experienced significant bleeding. I wasn’t in any pain but the blood had soaked through my clothes on to the sofa. From that moment things changed but at no stage were any plans to change my care discussed with me.
“The day Kit was born should have been the happiest of our lives but it turned to absolute despair. I don’t think we’ll ever get over leaving hospital and not taking Kit with us to start our new lives together.
“We’re so thankful and feel so blessed that we have Cooper and Jude, but it’s difficult that Kit isn’t at home with the four of us. Kit will always be part of our family and we’ll always love him. However, we’ll always believe he was badly let down.”
The couple added that parents should trust their instincts and ask any questions to medical staff to ensure they’re happy with their care. They hope their efforts to improve care will mean Kit’s death was not totally in vain,
Parents need to trust their instincts and know it is ok to ask questions of medical staff to ensure they’re happy with their care. There continues to be too many families affected by poor maternity care that we can’t sit by and do nothing.
“We were left trying to grieve for our baby while facing a complex system,” Sarah continued. “At times it felt like our concerns weren’t being listened to by the Trust. We felt they were defensive and we were made to feel like a burden for wanting answers. If it wasn’t for the help and support we’ve received over the last few years, I’m not sure we’d have coped.
Following Kit’s death in March 2021, Sarah and Andrew chose for a post-mortem examination to be carried out. It found that Kit died from a brain injury as a result of being born with no detectable heart rate, caused by the significant bleeds suffered by Sarah and an inflamed placenta. An inquest was not held into his death.
‘We are looking to improve future practices’
A Lewisham and Greenwich NHS Trust spokesperson said: “We are deeply sorry for the circumstances surrounding the death of baby Kit and the profound impact of this on Sarah, Andrew, and their wider family. Following Kit’s death, the Health Services Investigation Branch, (now known as Maternity and Neonatal Safety Investigations) conducted an independent review of the care we provided to both Sarah and Kit, and they offered recommendations to improve future practices.
“We developed an action plan to address these recommendations, which was shared with Sarah and Andrew. These changes have been fully implemented, and we are committed to continuing to listen and improve.”
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