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Parents furious over falsified records after baby's death

Marie-Louise Connolly
BBC NI health correspondent
BBC A couple standing in a kitchen looking into the camera. The man has a brown jumper on with a zip. He has brown hair and blue eyes. He is pictured beside his wife. She has brown hair with blonde highlights, blue eyes and is wearing a silver necklace. There are kitchen cupboards in the background. BBC
Martina and Ryan Tierney, parents of Mallaidh who died at 34 weeks in the womb

A couple whose daughter Mallaidh died at 34 weeks in the womb have accused the Southern Health Trust of a "cover up" after they discovered medical notes had been falsified.

Martina and Ryan Tierney said their concerns and calls for help were ignored for many hours before midwives confirmed there was no foetal heartbeat.

A report by the Northern Ireland Public Services Ombudsman (Nipso) into what happened at Craigavon Area Hospital Maternity Unit (CMU) in October 2021 found failings resulted in "catastrophic consequences for the patient and her daughter".

The trust apologised for the "failings identified by the ombudsman" and offered its deepest condolences to the family for its devastating loss.

"The trust continues to work on fully implementing the recommendations made in the Nipso report," the trust statement added.

"Our maternity team continue to implement the learning arising from this sad and tragic case."

'High risk pregnancy'

In October 2021, Martina, from County Tyrone, was 38 and her pregnancy was considered "high risk" following previous complications, including a miscarriage.

The couple had two other daughters when they discovered they were pregnant in 2021.

At 34 weeks pregnant Mrs Tierney was admitted to CMU on Friday 8 October 2021 after experiencing "severe" abdominal pains.

"I asked for help, but I was told to calm down, that everything would be ok, but the pain got worse," she told BBC News NI.

On admission a CTG (cardiotocography) was carried out by a midwife who confirmed the baby's heartbeat.

As the next 36 hours progressed so did the pain, and intravenous paracetamol and codeine were administered separately.

Ms Tierney was described as "high risk" after previous complications including a miscarriage

Midwives and a junior doctor told Mrs Tierney that a Caesarean section had been ruled out for the evening of 9 October as they wanted to wait until morning.

However, in the early hours of Sunday morning when Martina could no longer get off the bed due to the pain, she told a midwife she could not feel the baby move.

At about 05:30 two CTGs and a scan could not find a foetal heartbeat, and Martina was told the baby had died.

"I was just numb, however those feelings turned to anger because I hadn't been listened to. That anger then turned to guilt because maybe I should have shouted louder - but I know I did shout - just no-one listened," Martina said.

Ryan Tierney said losing his daughter Mallaidh and everything that happened both prior to her death and following it had been "harrowing".

He said "the ombudsman's report has been scathing", claiming that there had been "an attempted coverup, notes went missing and falsified, we are fuming".

"Our daughter was perfect, absolutely perfect and that's what makes it all so frustrating, it was all completely avoidable," Ryan said.

Fundamental failings - Nipso

An investigation by the NI Public Services Ombudsman (Nipso) into what happened identified "fundamental failings" in the CMU staff's care and treatment of Martina Tierney.

Ombudsman Margaret Kelly said based on her findings - including if the patient had been escalated for senior review - the "outcome would have been different and her baby probably would have been born alive."

Other findings included:

  • If the patient had been escalated and an emergency Caesarean carried out on the balance of probabilities the baby would have survived
  • The midwife did not accurately record the patient's pain score
  • Midwifery and clinical staff did not escalate the patient's care to a senior doctor for review
  • Identified that the attending midwife made an entry in the patient's record on behalf of a colleague which does not accord with the NMC Code
  • The maternity unit was understaffed on 9 October 2021
Martina and Ryan Tierney A black a white image of a baby's feet with hands around them pointing their fingers together to shape a heart. The baby's feet is pictured in a white blanket. Martina and Ryan Tierney
The Tierneys say they are grateful they got to spend two days with Mallaidh

Inaccurate recording of pain

The ombudsman said based on the evidence a turning point in Mrs Tierney's care happened on the Friday night.

The level of pain should have alerted staff to escalate the patient's care.

Also inserting notes about a patient on behalf of another nurse according to Margaret Kelly was "concerning".

The ombudsman told BBC News NI she had referred her report to the Nursing and Midwifery Council.

"In this case there was the falsification of records and in particular a midwife who said she was with Mrs Tierney and made a record to that effect when she wasn't.

"To me, that does contravene the professional code of conduct."

The Tierneys said they are grateful they got to spend two days with Mallaidh in the hospital's bereavement room.

However, Ryan said having to carry her coffin from the hospital and through the public car park to the Mortuary was as difficult as burying his daughter a couple of days later.

"That walk passing all the traffic was so tough," Ryan said.

A Serious Adverse Incident Report, carried out by the trust in November 2022 found the increase in pain was "inaccurately recorded which meant the patient wasn't escalated for a senior medical review."

Among its recommendations that the Practice Development Midwife will reinforce accurate recording of observations when completing charts and when staff should escalate concerns.