A mother-to-be went to hospital suffering from massive internal bleeding from a ruptured artery but was told that she had trapped wind, an inquest was told.
The woman, Kimberley Newark, went back when her condition worsened and needed an emergency caesarean section. Her baby daughter, Olivia Trupiano, died five days later.
Details of their care and treatment were the subject of an inquest at West Sussex and Brighton and Hove Coroner’s Court, in Horsham. The coroner, Joanne Andrews, recorded a narrative verdict, finding that warning signs had been missed.
Afterwards, Ms Newark and her partner Yann Trupiano, who live in Brighton, spoke of their devastation and anger over the warning signs that might have prevented their newborn daughter’s death.
A broader inquiry is under way into maternity services at University Hospitals Sussex NHS Foundation Trust which runs the Princess Royal Hospital, in Haywards Heath, where Olivia was born, and the Royal Sussex County Hospital, in Brighton, where she died.
The parents had hoped for answers at the inquest to questions about the warning signs that were missed before a life-threatening emergency for both mother and baby.
Olivia Trupiano was born on Saturday 14 September 2024 with a severe brain injury, after Ms Newark had to have an emergency caesarean section at the Princess Royal.
Doctors found that a major blood vessel near Ms Newark’s stomach, the splenic artery, had burst, causing massive internal bleeding and a life-threatening loss of an estimated 14 litres of blood.
Olivia, who was born at 34 weeks, died five days later.
In the hours leading up to her birth, Ms Newark and Mr Trupiano said that they repeatedly raised concerns about Ms Newark’s worsening condition.
But maternity staff at the NHS trust did not appreciate the seriousness of her condition and the couple told the inquest that they felt “ignored and dismissed” despite repeated warnings about her deteriorating health.
The trust’s maternity services are under investigation after a review – led by midwife Donna Ockendon – commissioned by the former Health Secretary Wes Streeting.
It follows a meeting at which nine bereaved families raised concerns over the deaths of their babies from 2021 to 2023.
Ms Newark and Mr Trupiano, who have been in contact with the other families, said that their grief at losing their daughter was made “so much worse” by learning that several parents had endured disturbingly similar experiences.
Ms Newark said: “I went to the hospital because I had fainted, was weak, dizzy and in excruciating pain – pain I knew was not normal.
“They told me I had ‘trapped wind’ and administered Buscopan alongside pain relief and IV (intravenous) fluids. My pain never subsided and it turned out I was bleeding internally.
Mr Trupiano said: “Our daughter died and Kimberley nearly died too – I put my trust in the medical staff.
“I was told to go home overnight and come back in the morning and believed that Kimberley was in safe hands.
“Shortly after I left, I was called to say she was having an emergency caesarean and she was in a critical condition.”
Olivia needed to be resuscitated at birth and was found to have severe hypoxic ischaemic encephalopathy. The condition occurs in a baby when the brain does not receive enough oxygen or blood flow at around the time of birth.
After emergency surgery, Ms Newark was placed in a coma. She and her daughter were transferred to the Royal Sussex where Olivia died on Thursday 19 September 2024.
After the inquest, Ms Newark said: “Following the conclusion of the inquest, we have now heard the verdict of the investigation into Olivia’s death.
“This has been an incredibly difficult and emotionally exhausting process for Yann and I as Olivia’s parents because the devastating reality is that our baby died and I nearly died too.
“Throughout our involvement in this process, with the support of our legal team at Slater and Gordon, our reason for being here is simple: to seek answers about what happened to Olivia, to understand the circumstances of her death, whether anything could have been done differently and to ensure that any lessons that can be learned are not lost.
“While today’s findings do not provide all the answers we had hoped for, we welcomed the opportunity to have the evidence fully investigated and to ensure that Olivia’s short life is never forgotten.
“Although we acknowledge the coroner’s conclusion, nothing can lessen the pain of losing a child and coming to terms with what happened remains incredibly difficult.
“We hope that this inquest will help ensure that lessons are learned wherever necessary and that greater awareness and continued learning about pregnancy-related emergencies may help other families in the future to receive the safest possible care.
“Olivia was our beautiful and much-loved daughter. She mattered and she should never be reduced to what happened to her medically.
“Although her life lasted only a few precious days, she brought immense joy and love into our lives and will always be a cherished part of our family.
“She will always be loved, missed and remembered and not a day goes by that we do not think about her. Her loss has left a devastating void in our lives.
“We hope that her life, and the impact of her death on our family, will be remembered with humanity, dignity and care.
“Olivia should still be here with us and every day we think about the life she should have had and the memories we will never get to make with her.
“She should be growing up alongside her siblings, who have had to live with the loss of a little sister they were so excited to meet and that is something that has affected our entire family profoundly.
“Today is not a day of closure for us, because there can never truly be closure when a child dies. Instead, it is another step in our ongoing journey of grief.
“We will continue to cherish Olivia’s memory and remember the joy and love that she brought into our lives, however brief her time with us was.
“Olivia is deeply loved and will never be forgotten. She will remain in our hearts forever, and we will continue to honour her memory every day.”
Ayesha Hussain, clinical negligence solicitor at Slater and Gordon, representing Olivia’s family, said: “Olivia’s family has shown remarkable strength throughout the inquest process while living with the devastating loss of their much-loved baby.
“The evidence heard during the inquest was complex and the coroner indicated that there were opportunities for improvement in communication.
“While no legal process can remove the grief associated with such a profound loss, the family hope that increased awareness of medical conditions such as splenic artery rupture may contribute to medical learning and support efforts to improve outcomes wherever possible.”
I’m terrified by the thought I could be sent to a Sussex hospital one day. I believe that RSH Brighton still employs the gastro surgeon known to his colleagues as Dr Death. I’d rather go to London where, I believe, the top doctors are
Bogus qualifications?
Perhaps we should all get out those pots and pans every time the NHS kills another person through incompetence?