Elsie Poole lived only 21 short months, passing away on 25 January 2013. Katherine Sirrell from the medical negligence team at Leigh Day and Elsie’s mother Holly recount the circumstances which led up to her death three years ago.

Holly Poole had a difficult and eventful pregnancy with Elsie, experiencing constant and severe headaches from 21 weeks gestation. On 16 March 2011, when Holly was at 34 weeks gestation, she was referred to East Surrey Hospital Antenatal Day Unit by her GP with suspected 'fetal tachycardia', where the fetal heart rate is too high, but the fetal heart rate (CTG) monitoring was recorded as reassuring.

At 36 weeks gestation Holly was referred again to East Surrey Hospital by her midwife for her intense headaches, visual disturbances, feelings of dizziness and swollen face, legs and ankles. Again, CTG monitoring was undertaken, but this time the doctors identified decelerations in her fetal heart rate.

A registrar was asked to review and once again it was concluded the trace was reassuring. Just a couple of days later on 4 April, Holly went back to East Surrey concerned that the baby’s movements had decreased in frequency.

She was told to come back if she felt the baby moved less than ten times a day. On 7 April, now at 37 weeks gestation, Holly felt ‘odd’, so took herself back to East Surrey and again Elsie's heart rate was monitored.

Shallow decelerations were noted and Holly was told that her baby was in distress. Yet, according to Holly, she was told to come back the next day for further monitoring. Holly came back the following day, a Friday, and the CTG trace was recorded as suspicious at 12:35pm, again at 2:50pm but then at 4:15pm it was noted that the heart rate was reassuring.

Holly was sent home, the plan being she would return on Monday, three days later, for further monitoring. Holly followed the advice of her doctors, and returned on the morning of Monday 11 April 2011. A CTG was commenced and her doctor told her that Elsie was in distress. She was told shortly after 9am that the doctors were unsure if the umbilical cord was wrapped around Elsie's neck.

According to the hospital notes, at 10.15am Holly was 4cms dilated and a plan for caesarean section was made. She was told then that she was in established labour, but it was not until after 2pm that Holly was taken to theatre and Elsie was born at 3:18pm.

By that time, Elsie was so far down the birth canal that she had to be pulled back up with forceps.

“I remember there being a lot of bruising around Elsie's face, especially around her right eye. I was ecstatic of course that I had given birth, and relieved after days of worrying about her heart rate, but it was a shock to see her newborn with a black eye and bruising to her face.

“I remember Elsie having seizures from the very first evening, but the hospital notes do not record this until 22 May 2011 even though I told the staff. From once she began twitching, she was in an almost constant state of seizure.

“Elsie received continual intense emergency medication. It was absolutely heartbreaking to see her little body suffering in such a way.

“We instinctively felt that something had gone wrong in her care and approached Leigh Day’s  Medical Negligence team who began to investigate our case."

Holly Poole

Elsie spent the majority of her short life back and forth to hospital, and spent eight weeks at the Shooting Star Chase Hospice over the summer of 2011.

Ambulances were called out multiple times for Elsie and she frequently received emergency medical attention, but on 25 January 2013 she passed away aged 21 months, as a result of her brain injuries.

Holly explained how devastated she and her husband were by her death of Elsie:

It breaks my heart that she suffered during her short time here but saying goodbye was so hard. For a short while we just wanted to be left to grieve, but then I had a renewed need to get answers.

“Before her death, I had wanted to have the hospital apologise for any mistakes that might have been made and for them to assist with Elsie's care and hospice costs, but since her passing I have longed for answers.

“We felt the doctors at East Surrey didn't want to talk about what happened in April 2011 and there was never any report or investigation. We never even received a letter from them about it.

“We asked Leigh Day to renew their efforts to uncover the truth, and to instruct medical experts on our behalf to give their views on what happened to Elsie.

Holly Poole

As Holly's legal team we sought expert advice on the standard of care mother and baby received.

Our expert obstetrician advised that Holly should never have been sent home on Friday 8 July 2011 and told to wait three days to return before any further monitoring could take place.

“It was hard hearing that it was an independent expert's views that mistakes were made in mine and Elsie's care on 8 April 2011. It does make you think what if, and should I have done more?

“It is incredibly emotionally demanding to be told something like that, but it was so much worse not knowing anything at all. “At least now we had one piece of the puzzle. We asked our solicitor Katherine Sirrell to contact the hospital on our behalf.”

Holly Poole

We had notified the legal services department at East Surrey hospital in August 2013 that we were investigating a potential claim against their hospital.

In October 2015 we notified them that we had received independent medical expert advice that the care Holly Poole had received on 8 April 2011 was substandard but that we had clear instructions from Elsie’s parents that they did not intend to pursue a damages claim – instead they sought reassurance that steps would be taken to prevent similar tragic and avoidable errors in the future.

They also sought a charitable contribution to their fund raising effort for the hospice who had provided much needed respite care for Elsie during her short life.

We wrote to East Surrey Hospital inviting their full response to the following:

“We do have clear instructions from Mr and Mrs Poole not to pursue a damages claim against the trust despite the failure correctly to read and interpret the CTG traces on 8 April 2011 and the delay in delivering Elsie by caesarean section.

However, the family (and incidentally, we) feel it is very important that the Trust recognise mistakes were made and deal seriously with their concerns. Elsie and her family went through a terrible tragedy, the pain of which will linger on, but it is important to them to know that mistakes made by those doctors and midwives responsible for Mrs Poole’s and Elsie’s care are recognised and acknowledged.

More than an apology, the family would take comfort in knowing that appropriate training is given and systems are put into place to avoid these mistakes happening again and others suffering the loss and misery they have endured.

We invite you to respond with an explanation of why the CTG trace on 8 April 2011 was misinterpreted, a recognition that mistakes were made by those entrusted with Holly and Elsie’s care, and what measures have been put in place to ensure similar mistakes will not happen again.” 

Unfortunately, we heard nothing from the hospital for weeks until eventually in mid December 2015 we heard that, on the basis of our letter, there would be a preliminary investigation into whether this case warrants a full scale investigation into and report on potential failings in April 2011.

"The news that the hospital were considering whether the circumstances surrounding Elsie's birth should have been investigated is insulting.

“We are very frustrated that it has taken this long for the hospital to consider launching an investigation and report into the circumstances surrounding Elsie's care and management and that it took our solicitors and independent expert medical advice to kick start investigations, almost five years after the initial events.”

Holly Poole

It's important that any mistakes, wherever and whenever they occur, are learned from and that patients are reassured that systems are put in place to avoid them happening again.

It means so much to Holly and her husband Martin to get the apology they have waited for and to know the full circumstances relating to their daughter's birth and tragic death.

It should not be the case that families need to resort to pressuring hospitals with solicitor's letters and independent expert advice in order to trigger internal hospital investigations, years after the incident has occurred.

We are privileged to have been able to help Holly move towards getting some of her answers but worry that other families, without the same information and advice, will never ever get the answers they deserve.

“We continue to wait for answers and an apology, which is important to us, but we want Elsie's legacy to live on.

“The Hospice did so much for our family and we continue to fundraise for them to support the vital work that they do and priceless assistance they give to other families like ours.

We have a justgiving page and have so far raised over £63,000 (www.justgiving.com/elsieviolet) and hope to continue to fundraise this year with a fun run planned for April 2016.

We have also asked East Surrey to make a donation to the appeal. We hope this money goes some way in helping others and keeping Elsie's memory alive.”