Pregnant woman who was told she was constipated and sent home from hospital despite being in severe pain gave birth on the kitchen floor and her husband was unable to save his premature daughter

• Jennifer Handy died at Prince Charles hospital hours after she was born 
• Her mother Sarah had been sent home hours earlier on April 10, 2017 
• A doctor missed Mrs Handy’s sepsis, believing instead she had constipation
• Her inquest recorded a narrative conclusion as she was ‘too small to survive’
• WARNING: GRAPHIC CONTENT  

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A father desperately tried to breathe life into his prematurely-born baby after her pain-stricken mum was sent home from hospital told she was constipated, an inquest heard.

Despite his best efforts, Jonathan Handy’s daughter Jennifer died at Prince Charles Hospital in Merthyr Tydfil, south Wales, on April 10, 2017.

Mother Sarah had given birth at home in agony, bleeding heavily and suffering from an infection, Pontypridd Coroners’ Court heard.

Jonathan and Sarah Handy, pictured outside Pontypridd Coroners’ Court today heard how their daughter Jennifer may have survived her mother had not been sent home from hospital hours before she gave birth prematurely 

Mr and Mrs Handy, pictured with their daughter Jennifer, were told at the infant’s inquest that if Mrs Handy had been in hospital at the time of the delivery, their baby may have survived. (Mr and Mrs Handy have given permission for the use of this image)

Coroner Rachel Knight said Jennifer, who had been born at just 26 weeks, would likely not have died that day if a doctor at Prince Charles Hospital had not sent mother Sarah Handy home.

In a statement after the inquest concluded, the family said that they were ‘completely heartbroken and will never get over the tragic loss of our daughter’.

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The doctor who saw Mrs Handy has since left the country and hospital management apologised saying they were ‘deeply sorry’.

Jennifer was one of 26 babies who lost their lives over a three-year period between January 2016 and September 2018 which is being investigated in a review by Cwm Taf University Health Board.

The inquest heard that Mrs Handy had attended Merthyr’s Prince Charles Hospital on April 9, 2017 after suffering from severe abdominal pain.

The court was told Mrs Handy was initially seen by a midwife but had to wait two hours to see a doctor. When she was seen by the doctor, she said she was concerned that she was in labour.

Mrs Handy said the doctor ‘reluctantly performed’ a cervical examination which caused a significant bleed, but the medic described this as ‘normal’.

Mrs Handy, pictured with her husband, required emergency treatment after she was rushed back to hospital having lost 2.5 litres of blood

After the examination, the doctor told Mrs Handy she was suffering from constipation and prescribed her paracetamol and laxatives.

The doctor told Mrs Handy a blood test was not necessary as she had one the previous Tuesday which showed no signs of infection.

Mrs Handy was discharged and returned to their home in Merthyr Tydfil but she continued to bleed and, despite taking the highest dose of paracetamol allowed, she was still experiencing intense pain throughout the day.

In the early hours of the following morning, Mrs Handy felt as if she needed to push.

Mrs Handy said: ‘I said to Jonathan something was wrong and asked if he would take a look.

‘I led down on the bed and Jonathan said ‘oh my god, I can see the baby’s head’.

‘I must have gone into shock because I was unable to move and I felt weak.’

As Mrs Handy kept falling in and out of consciousness, Mr Handy called his mother, Vivienne Handy, who lived next door, and rang an ambulance.

When he returned back to the bedroom he saw baby Jennifer on the bed by her mother.

Mr Handy said: ‘I placed her on the mattress and I could see she was moving her arms and legs.

‘Her head went back and her mouth was opening as she was gasping for breath.

‘I focused on her chest and I could see it wasn’t rising or falling. I rubbed her gently and said ‘come on little one, come on’.’

Mr Handy tried to clear Jennifer’s airway and performed CPR and mouth-to-mouth resuscitation with the direction of the ambulance operator.

Mr Handy’s mother later arrived in the room and took over chest compressions.

Mr Handy said: ‘Moments later (Jennifer) seemed to recover again, took a really big gasp and stretched her arms and legs out.

‘I was in disbelief but she seemed to settle down as if she was going to sleep.’

While Jennifer was being treated by her father, Mrs Handy remained seriously ill and was bleeding profusely.

The paramedics arrived just before 2am and Jennifer was taken straight to hospital, with Mr and Mrs Handy following in another ambulance shortly afterwards.

When they arrived at Prince Charles Hospital, Mrs Handy was taken to A&E so she could be prepared for emergency surgery but before she was taken to theatre, a doctor came to tell her that Jennifer had died.

It was established that Mrs Handy had a sepsis infection in her lungs and bloodstream and had suffered a postpartum haemorrhage, resulting in a loss of 2.5 litres of blood.

She needed further surgery and was kept in the intensive care unit until she was discharged on May 16.

When they went to register Jennifer’s death, Mr and Mrs Handy were asked to fill out a stillbirth certificate and her death was formally classified as a stillbirth, but this later played on their minds as they believed Jennifer was alive when she was born.

Mrs Handy said: ‘I feel it’s important to change the classification of Jennifer’s death because she fought so hard to survive and we feel this should be recognised.’

The court was told Mrs Handy had complications during her pregnancy including type one diabetes, hypertension, cardiomyopathy and her waters had broken at 19 weeks, which increased the risk of infection.

A post-mortem examination was carried out following Jennifer’s death by paediatric pathologist Dr Sergey Popov.

Speaking at the inquest, Dr Popov said there were no definitive features of a live birth but there was nothing to preclude Jennifer being alive at the time of her birth.

He gave a cause of death as extreme prematurity and a secondary cause of chorioamnionitis.

Ruling on whether Jennifer had shown signs of life after her birth, assistant coroner Rachel Knight said: ‘I have heard evidence that Jennifer Handy moves her arms, threw her head back and gasped for air. The evidence is powerful and clear.

‘In my view it would be inaccurate for the terms stillbirth or stillborn to be used and I find for a fact that Jennifer showed signs of independent life.’

The court heard that Cwm Taf University Health Board had accepted that Mrs Handy should have been admitted to hospital for observations on April 9 and offered an apology for its actions.

The doctor who treated Mrs Handy on April 9 – known as Doctor A – had moved on from the hospital and left the country shortly afterwards and efforts to contact him have been unsuccessful.

In her conclusion, Ms Knight said had Mrs Handy been kept in hospital by Doctor A, there would have been close monitoring and she may have been transferred to a neonatal unit where better facilities could have been available.

Ms Knight said: ‘I find on the balance of probabilities that Jennifer would not have died at 2.02am on April 10.

‘I find the decision not to admit Sarah Handy was a mistake by doctor A and contributed to Jennifer’s death.’

A narrative conclusion was recorded by Ms Knight which said that Jennifer was ‘simply too premature to survive’.

Speaking after the hearing, Mr Handy said: ‘As a family we are absolutely devastated at the death of Jennifer, our much-loved and wished-for daughter and granddaughter.

‘The inquest today has been emotionally draining and had brought back the horrific details of what we went through almost two years to the day, ending with the loss of Jennifer.

‘We are still completely heartbroken and we will never get over the tragic loss of our daughter.

‘As a family it has been very important to us to understand what happened so that lessons can be leaned. We hope that today will be a step forward in that process.

‘We also hope that the findings of the health board’s ongoing review into its maternity services will go some way to improving the care and service given to patients so that other families won’t have to suffer in the same way we have suffered.’

In a statement, Cwm Taf University Health Board said: ‘Losing a baby is a devastating experience and we are deeply sorry for the failings in care and the significant distress caused to Mrs and Mr Handy.

‘We take our responsibilities for providing safe and high quality services extremely seriously and we are determined to do everything we can to ensure that we provide women and families with the best possible care.’ 

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