Stillborn baby after heart monitor alarm was set to silent

Summarised from 2 outlets · Updated 11 Oct, 11:48 · Archive

A baby was delivered stillborn after a heart monitoring machine's alarm was set to silent, masking a paper jam that prevented staff from noticing a dangerous drop in heart rate.

Bethany Sowerby, 32, was admitted to James Cook University Hospital in Middlesbrough after becoming worried about her unborn baby Hattie's movements whilst 38 weeks pregnant. Staff connected the baby to an electronic heart rate monitor whilst attending to other patients. Around 30 minutes later, Mrs Sowerby noticed the monitoring machine had suffered a paper jam.

Because the alarm was set to silent, staff did not immediately notice the problem and the drop in heart rate it had caused. Mrs Sowerby alerted staff to the jam, after which they found Hattie's heart rate was below the normal range. An ultrasound scan found her heart rate had dramatically slowed, and doctors decided she needed to be delivered immediately by emergency caesarean section. Hattie died on 16 May 2023.

An independent inquiry by the Healthcare Safety Investigation Branch found that the alarm for the electronic monitoring machine had been triggered by the paper jam but the settings had been switched to silent. A reprint of Hattie's heart rate showed it to be pathological, but this was not recognised before she died. The inquiry concluded that failing to recognise the dangerous reading, which indicated the baby was in distress, was likely to have contributed to her death.

Mrs Sowerby has since been diagnosed with post-traumatic stress disorder and is undergoing therapy and taking medication to cope with the loss of her daughter.

How it is being reported

• Tragic mum has stillborn baby after heart-rate monitoring machine was switched to silentMum loses baby after heart monitoring machine error: "I carried her for nine months and we couldn't wait to meet her and introduce her to her sisters."The Mirror · 11 Oct, 11:30
• Baby dies after heart monitor suffers paper jamMum Bethany Sowerby was left devastated by her baby’s death (Picture: Getty Images Europe) A baby was delivered stillborn after staff failed to notice a paper jam on a monitoring machine because its alarm was set to silent, an inquiry has found. Bethany Sowerby, 32, was taken to the James Cook…Metro · 11 Oct, 10:49

In this story: Bethany Sowerby · Hattie · James Cook University Hospital · Healthcare Safety Investigation Branch · Middlesbrough · Redcar

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