A grieving Scots family say they are still searching for answers after their baby tragically died following a ‘perfect pregnancy'.
Ashleigh Innes, 33, and Christopher Cummins, 29, were expecting their second child as they headed to hospital on 5 July, 2020.
Ashleigh, who was already a mum-of-one, arrived at Edinburgh Royal Infirmary’s Simpson Centre for Reproductive Health to be induced at around 1pm.
The 33-year-old was ten days over her due date but had enjoyed the 'perfect pregnancy'.
Due to Covid regulations at the time, dad Christopher wasn't allowed to be with Ashleigh until the birth.
Mum Ashleigh, from Ormiston in East Lothian, told the Daily Record : “I was nervous, but I was also excited to finally not be pregnant anymore and meet our son.
“My pregnancy had been absolutely perfect, I didn’t even have headaches or urine infections, and they are both fairly common."
She was admitted to a ward with other expectant mums while waiting to be induced.
A midwife and student midwife attached a Cardiotocograph (CTG) machine to check her baby's heartbeat trace, and she excitedly sent Christopher pictures of what was happening to keep him updated.
"The baby's heartbeat was fine. I felt elated and excited, all the feelings you get pending the arrival of your baby", she explained.
Ashleigh said that after her midwife returned from a lunch break the (CTG) machine was removed for an internal examination.
A Cook's Balloon, used to gradually dilate the cervix, was then inserted by her midwife to help start labour.
The heavily pregnant mum was advised to alleviate discomfort from the balloon by walking around the ward.
Ashleigh said she noticed water on the bed as she moved to stand up, and then noticed water at her feet but assumed it was saline solution from the Cook's balloon.
But the mum became panicked after noticing blood when she went to the toilet.
She continued: "The balloon was only in around 20 minutes when I stood up and there was a little bit of water on the bed. There was also a little pool of water at my feet. I thought it was just the saline leaking out from the balloon.
“But I went to the toilet with a change of clothes and realised there was blood on the toilet seat and quickly went back to my bed and sounded the alarm.
"I went back to the toilet and waited for my midwife to come because I wanted her to see the blood and I also didn't want the two other women on the ward to see what was happening.
Ashleigh alleges it took 20 minutes for her midwife to arrive despite sounding the alarm.
She also claims she had to ask three members of staff to get her midwife for help.
She told the Record: "I waited outside the toilet and a clinical support worker came in. I told her I didn't feel right and there was blood coming out. She turned off the alarm and said she'd go and get the midwife.
“Another woman in a non-nurse’s uniform came in and I asked her where the midwife was, she said she’d go get her.
"I was standing waiting at the toilet and peeking out periodically. Then I saw the student midwife on the ward and asked if the midwife was coming because I’d asked three times now.
“I was becoming panicked at this point because I knew something wasn’t right."
The student midwife assessed Ashleigh and established her waters had broken.
When Ashleigh's midwife returned, a (CTG) machine was attached for the second time to check for her baby's heartbeat.
But the alarming findings triggered an emergency buzzer.
The monitor showed the baby's heartbeat had dropped dangerously low to just 50 beats per minute.
Ashleigh's consultant was called to the ward and told her there had been a cord prolapse - which occurs when the umbilical cord slips down in front of the baby after the waters have broken.
Ashleigh was immediately prepared for an emergency C-section to save her baby's life.
Reliving those moments, she said: "The midwife arrived and I’d been waiting at least 20 minutes.
"She put the heartbeat monitor back on and straight away she knew something wasn’t right and pushed the crash alarm and withdrew the Cook's balloon.
“Within a few seconds, my room was filled with people.
"The consultant checked me over and detected there had been a cord prolapse and told me they would have to put me to sleep.
“The room was chaotic and I was in a state because I didn’t know what was going on.
“I was really panicked because I’d never been put to sleep before but at the time I didn't know anything about a cord prolapse or how serious it was.
“I asked for an epidural and they said I could if I wanted but that they really needed to get the baby out.”
Dad Christopher didn't make it to the hospital until the C-section was underway and was asked to wait outside until Ashleigh was taken to a recovery room.
Their son Connall Ian Cummins was born with no heartbeat at 4:29pm.
The parents later found out that it took staff '18 minutes' to try to resuscitate him.
Little Connall was transferred to the neonatal unit for round-the-clock care.
But parents Christopher and Ashleigh were left heartbroken as his doctor told them he would be unlikely to survive.
Ashleigh said: "His body was cooled to try and limit brain damage but it was already too late.
"We were told he was severely brain-damaged and wouldn't survive, or, if he did, he would be in a 'vegetative state'."
Connall tragically passed away at four days old on July 9 at 8:55pm.
His cause of death was determined to be severe hypoxic-ischaemic encephalopathy (HIE) - a lack of oxygen and blood flow to the brain at birth - caused by a cord prolapse.
An NHS Lothian review into Connall's death, released to the family in December 2020, did not identify care or service delivery issues that led to his death.
But Ashleigh and Christopher say they are still searching for answers following the findings of the review.
The parents, who share son Jayden, 14, and four-month-old daughter Skye, have questioned why it allegedly took 20 minutes for a midwife to respond to Ashleigh sounding the alarm when she began to bleed, and removing the Cook's Balloon.
The review report also states it was the midwife's ‘usual practice’ to listen to the baby's heartbeat following insertion of the Cook Balloon, with clinical guidelines advising that a handheld machine called a sonicaid should be used.
Ashleigh claims this did not happen and the review confirms this step was not documented by the midwife in her medical notes.
The family believe had a heart trace (CTG) or sonicaid been used after the Cook's Balloon was fitted, medics could have spotted a cord prolapse sooner.
She added: "It could have monitored the baby's heartbeat if the cord prolapse was going on from the time the Cook's Balloon was inserted.
“A cord prolapse is the biggest emergency you can have in a pregnancy. For us, it was fatal and my baby was healthy throughout the pregnancy."
Christopher and Ashleigh say the loss of Connall has permanently changed their lives.
Ashleigh struggled with anxiety after the traumatic experience of losing their child.
She added: "The loss of Connall has been horrific. I don’t think anything can compare.
"I'm always thinking about him. You're always going to wonder what could have been. I'll never see him grow up.
"I've been left traumatised. I have suffered from really bad anxiety since, and had to take medication to deal with it."
When contacted by the Record about the parents' questions, NHS Lothian said patient safety is their 'top priority' and take complaints 'extremely seriously'.
The health board said their report provided a 'factual account' of Ashleigh's care.
Pat Wynne, Interim Nurse Director, NHS Lothian, said: “We understand this is an extremely difficult time, and we express our sympathy for the distress Ms Innes and her family are experiencing.
"Ensuring patient safety is our top priority and we take all complaints extremely seriously. NHS Lothian carried out a thorough review of the care Ms Innes and her baby received.
"The review did not identify care or service delivery issues that led to the death of Ms Innes’ baby.
"A detailed written response and accompanying report was provided to the family in December 2020.
"The report provided a factual account of the care that Ms Innes and her baby received and included detailed information from their medical notes.
"The review team was made up of a number of clinicians with expertise in obstetric and neonatal care. If the family has further questions about the report, we encourage them to get in touch with us directly."
