Alexander's story

It has been almost a year since I last wrote here.

Life has moved on in many ways. Jamie keeps me very busy and brings so much joy into my life, but Alexander remains part of my life every single day. There isn't a day that goes by without me thinking about him and wondering who he would have become. Alexander would have been eight in August this year.

The publication of the Nottingham Maternity Review has prompted me to write again. Today, I want to share what happened to Alexander, which I have never shared on this blog before.

As I read the stories of other families, I was struck by how familiar so many of the themes felt. Parents raising concerns that were not listened to. Failures to follow guidance. Opportunities to intervene that were missed. Families then facing years of defensive investigations before receiving acknowledgement that things had gone wrong.

Although Alexander was born in 2018 at a different hospital, many of those themes resonate with my own experience.

During my pregnancy, I attended hospital on four occasions because I was concerned about reduced foetal movements and once because I experienced unusual shaky movements. Looking back, I discovered that both national guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) and the Trust's own guidelines indicated that additional monitoring and scans should have been offered after 28 weeks' gestation. These included growth scans, cardiotocography (CTG), Doppler ultrasound, liquor volume assessment and consideration of a consultant review because of my repeated presentations. None of these investigations were offered.

During labour, there were also failures to recognise and escalate concerns appropriately. Alexander suffered an ischaemic brain injury during his birth and after sixteen precious days together, I had to say goodbye to my beautiful, brave little boy.

What followed was another long and painful journey.

For more than two years, I questioned why national and local guidance had not been followed. I was repeatedly told that it had been. It was only at the Coroner's inquest in 2020 that the Trust accepted that additional investigations should have been offered during my pregnancy and that the guidelines had been misinterpreted. The Coroner also concluded that the student midwife caring for me during labour had not been adequately supervised.

Those admissions could never change what had happened. They did, however, validate the concerns I had been raising from the very beginning.

One of the hardest parts of my experience was not only losing Alexander, but feeling that I had to fight for an honest account of what had happened. I wanted openness, reflection and learning. Instead, it often felt as though I was battling defensiveness. The initial Root Cause Analysis contained errors and a Serious Incident investigation was only completed more than two years later, after the Coroner became involved. That experience left me with concerns not only about what happened to Alexander, but also about how healthcare organisations investigate themselves when things go wrong.

The Nottingham Maternity Review has reminded me that my experience was not unique. While every family's story is different, there are recurring themes that should concern us all: the importance of listening to women, following evidence-based guidance, carrying out robust investigations and creating a culture where organisations are willing to learn when mistakes are made.

I will never get Alexander back. But his life mattered.

If sharing Alexander's story encourages even one healthcare professional, one hospital or one NHS organisation to ask difficult questions, follow guidance more consistently or investigate concerns more openly, then his legacy continues.

It has now been almost eight years since Alexander was born and five years since the Coroner's inquest. Time has not lessened the pain, nor the importance of learning from what happened. If anything, the publication of the Nottingham Maternity Review has reinforced why I believe it remains so important to continue telling Alexander's story, in the hope that lessons are learned, healthcare becomes safer for mothers and babies and other families are spared the heartbreak of losing a child.

Though his hand and foot prints are small, his mark on the world continues to grow.