Trust could not have prevented sad loss of unborn twin, but should have apologised for mistake

What happened

When Mrs R was pregnant, she went to an antenatal fetal assessment unit where staff carried out a number of observations.

A recording of the fetal heartbeat and uterine contractions (CTG) was performed and it was considered that this showed reassuring features.

The next day a doctor was asked to review Mrs R in the early morning because the fetal heartbeat for one of the twins could not be found. Medical staff carried out an urgent ultrasound that showed that one twin had died. The next day Mrs R had an emergency caesarean. E was live–born, but sadly, V was stillborn. Mrs R complained that if she had received appropriate management, both of her sons would have been born alive.

What we found

We noted that the Trust had accepted that staff should have noticed that the CTG the day before the caesarean was picking up just one heartbeat. The most probable explanation for why only one heartbeat had been recorded was that V had already died. Therefore, we concluded that there was no evidence to show that the fault in Mrs R's care led to loss of V's life, or that the outcome would have been different if the fault had not happened.

However, we saw that the fault, on its own, caused Mrs R distress. Therefore we considered that the Trust should have provided a clear apology that it happened.

Putting it right

The Trust apologised to Mrs R.