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Morecambe Bay Investigation - The Story of Ellis

Morecambe Bay Investigation - The Story of Ellis

In advance of the publication of Dr Bill Kirkup’s investigation report into the failings at Furness General Hospital, Kate Murray talks about the treatment she and her son Ellis received at the Maternity Unit in 2010.

Ellis Warburton was born at the maternity unit of Furness General Hospital on 27th July 2011. Ellis was the third child of Kate Murray (31) and David Warburton (33). Born against a background of numerous failings in the management of the labour and birth, Ellis weighed 7lb 11oz and was a healthy baby, save for a catastrophic brain injury.

He died on 28th July 2011 at the Lancashire Women and Newborn Centre at Burnley General Hospital. The cause of Ellis’ death was severe hypoxic ischemic encephalopathy (oxygen starvation). A Serious Untoward Incident report produced by University Hospitals of Morecambe Bay NHS Foundation Trust  identified numerous failings in the care of Ellis and his mother at Furness General Hospital.

Kate and David have three children and continue to live in Barrow in Furness. Kate is a nursery nurse and David is a contract worker. 

In advance of the publication of Dr Bill Kirkup’s investigation report into the failings at Furness General Hospital, Kate Murray talks about the treatment she and Ellis received: 

The labour 

"There had been no problems with my pregnancy and we expected that it would be a normal delivery. I went up to the hospital about 10.30pm on 26th July 2011 which was the day before my due date. I had been having labour pains all day. I had an initial examination and was only 1cm dilated. I was given the option to go home but since my Mam had come up to look after the older kids, I decided to stay.

Early in the morning on the 27th July, the midwives called a doctor to break my waters to try and get things going. I was told this had to be done by a doctor, rather than a midwife, because of the risk of cord prolapse.

I had been saying throughout that something didn’t feel right, but the midwives weren’t concerned about my reaction. I later found out that they thought I was being dramatic and irrational."

Ellis’ delivery 

"The head of midwifery took over my care at 8.00am. At 8.45am, they weren't able to detect Ellis' heartbeat and five minutes later, the prolapsed cord was discovered. Once they discovered the cord, they rushed me to theatre. It was a real emergency. The scar on my belly is very irregular as if it was a massive rush. 

Ellis was delivered by emergency caesarean at 9.01am.  They were very pleased that it had only taken 11 minutes to deliver him, but when he was born he was in a very poor condition. He has to be resuscitated and was given morphine. He was transferred to the Hospital’s NICU (Neo-natal Intensive Care Unit).

I woke up in the recovery ward and the midwife who delivered him had to tell me what happened. I then had a visit from the transfer team as they were going to take him to Burnley NICU where they had equipment to cool him down which was meant to protect him from further brain damage. 

I asked to see him and they organised for my bed to be wheeled to his door. I stayed at Barrow, but Dave and his Dad followed the ambulance carrying Ellis. A couple of hours later, they told me Ellis was really poorly and I should go to Burnley to be with him. I knew it was really bad. 

At Burnley I was put in a private room on the maternity ward. There wasn’t much they could tell us. I went to see him in my wheelchair. The amount of wire was horrendous. They were doing all the tests they could. The paediatrician said things like this shouldn’t happen. 

They sent me back to the ward for some rest and something to eat. Dave stayed in the room with me. We went back up to see Ellis in the middle of the night."

Ellis’ death

"In the morning we had a meeting with the consultant and the team. They told us there was no brain activity at all: Ellis would never been able to breathe on his own. We had no option. There was nothing anyone could do. They took the decision out of our hands really because they were so firm that there was no hope. 

My Mam brought the older kids through to Burnley. The nurses took all the wires out except the ventilator so we could all spend a bit of time with Ellis and say goodbye.

The worst bit was what the kids had to go through. As a Mam, they think you can fix everything, but here’s something you can’t fix. My daughter is the worst affected. When I was pregnant next, she was very anxious. I had my next baby at Burnley.

We came home and a couple of days later my GP visited. She was absolutely fantastic. She mentioned a “mother meeting” and asked if I would like her to arrange one. We agreed to that."

The hospital’s reaction

"Three of them came to our house - the consultant (who I’d never met before), the midwife who delivered Ellis and the Maternity Unit's matron. They basically made everything worse. They went through everything that had happened but when they left I felt like I’d done something wrong. They asked if I’d done this or that through my pregnancy. They asked if I had considered that Ellis might have had some underlying medical condition. They tried to turn it round on to him.

When I went back to Furness General for my six week check at the hospital, they didn’t even examine me. They just started questioning us about what had been in the papers. We asked for the root cause analysis and were told that it had been done, but it had to be checked.

We kept asking for this document. In the end, the police got it for us. It was hand –delivered to my door by a policeman and showed that there had been six key failings, four secondary failings and an individual failing. They have never accepted these 11 failings contributed to Ellis’ death."

The legal action

"My Dad had been following the story in the newspapers and it was him that said to get in touch with Burnetts. We were never interested in the money. Obviously we’d had financial losses, but we weren’t bothered – all I wanted was for them to admit they’d made a mistake and apologise. I told our solicitor that we would accept whatever she negotiated as long as there was a letter of apology. When it arrived, the letter was pitiful, but how could you ever write a good enough letter?

As part of the legal investigation, we got a statement from the paediatrician at Burnley. I wanted her view on whether or not there had been anything wrong with Ellis. She said there was nothing wrong with him whatsoever. "

The future of Furness General

"I feel awful when I see how many problems there are at Furness General Hospital. The town we live in, if you say anything negative, they say you are trying to shut the hospital down. Just because it’s the only hospital we’ve got doesn’t mean it shouldn’t be safe. It’s no good keeping it open for it to be rubbish. I hate to see my friends going to that maternity unit. 

It was never my plan to scare expectant mothers, but you still hear stories of pregnant ladies being told to “get a grip” when they express worries about their pregnancy or labour. The hospital has told the whole of the town, via the papers, that they have made changes but some things haven’t changed. Women shouldn’t be made to feel bad – any concerns raised by a pregnant woman should be taken seriously. 

I wish I could look back and say that it was devastating that Ellis died, but that something positive came from it, but I can’t."

Ellis’ parents brought a claim of negligence against the University Hospitals of Morecambe Bay NHS Foundation Trust which was settled in July 2014. The family’s solicitor was Victoria Watson, a specialist clinical negligence solicitor at Burnetts. 

End 

Ellis’ family will not be giving any additional statements or interviews. For further media information, contact Angela Huck at Burnetts on 01228 552222 | ash@burnetts.co.uk | 07525 128762

Note to Editor: 

Further information on the causes and consequences of cord prolapse can be found here: http://www.patient.co.uk/doctor/Prolapsed-Cord ;

Published: Saturday 28th February 2015
Categorised: Medical Negligence

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