A BABY died after midwives repeatedly missed signs her mum was in danger during labour, a report found.

Abigail Miller passed away just two days after she was delivered in a dramatic emergency C-section in a hospital reception area as her mother Katie Fowler went into cardiac arrest.

Midwives, who spoke to Fowler only over the phone, had twice missed chances earlier that day to bring her in for assessment, an independent investigation revealed.

They also failed to call an emergency ambulance when her condition deteriorated, it was found.

An inquest last week found Abigail would have survived if her mother had been called into hospital sooner.

Now Katie, 37, and her husband Rob Miller, 39, have joined other bereaved families in calling for a statutory inquiry into England’s maternity services.



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They say the errors that contributed to their daughter’s death included staff not having had time to do the right training or to manage phone calls correctly.

“The midwives who were in charge of our care were under extreme pressure – they were very stretched that night,” Rob said.

“We have come to realise this wasn’t about individual mistakes but about systemic problems.”

The couple had phoned the maternity unit at the Royal Sussex County Hospital in Brighton four times on January 21, 2022, after Katie went into labour on her due date, including two calls reporting blood loss.

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But their concerns were allegedly dismissed and they were told to remain at home until after their fourth call at 7pm.

At that point, Rob reported his wife had gone pale with blue lips and was struggling to breathe – but instead of calling an emergency ambulance, midwives agreed it was probably a “panic attack” and told the couple to make their own way to hospital, it is said.

In fact, Katie had massive internal bleeding caused by a uterine rupture – a rare birth complication where the womb tears.

The blood loss caused her heart to stop as their taxi pulled up outside the hospital’s main entrance.

Doctors from other departments rushed to save her by performing emergency surgery in a public lobby and creating a makeshift resuscitation area on two waiting room chairs as they attempted to stabilise Abigail.

Katie survived after spending two days in a coma in intensive care and was able to meet her daughter.

But despite medics’ best efforts, Abigail died in her parents’ arms later that day – at just 48 hours old.

Rob said it was impossible to put into words the trauma the family had been through.

“That night I was torn in two directions – my wife and my daughter were both so unwell in different parts of the hospital, there was a big question mark over whether either of them would survive,” he said.

“The last thing Katie remembers is being in the taxi on the way to hospital.

“For her to pull through, only to learn she was meeting Abigail so she could say goodbye to her only child – it’s just devastating.”

Speaking to BBC's Newsnight, Katie added: “To lose our daughter has destroyed us and to know things should have been different is impossible to come to terms with.

“Abigail should still be with us. We miss her every single day.”

To lose our daughter has destroyed us.

Katie said everything could have been different if she had been in hospital earlier.

“We were badly let down. We could have been spared this trauma,” she added.

A June 2022 report by the Healthcare Safety Investigation Branch (now renamed the Health Services Safety Investigations Body) found the maternity unit could not have diagnosed the rare complication over the phone, had missed two chances to bring Fowler in earlier that day and had failed to make an urgent 999 call when her condition deteriorated.

It added that a telephone advice line “is not designed to provide a diagnosis”.

If Katie had been in an ambulance at the time of her cardiac arrest, paramedics could have intervened, which may have affected “the outcome for the mother and the baby”, the report concluded.

The HSIB made two safety recommendations, both relating to improving the Trust’s maternity telephone triage service.

The Royal Sussex County Hospital’s maternity unit had been downgraded to “inadequate” by the Care Quality Commission (CQC) three months before Abigail’s birth, for reasons including understaffing and poor staff training.


Earlier this month, the CQC revealed two thirds of maternity units in England were not safe enough.

Abigail’s parents, from Hove, East Sussex, said: “The latest reporting by the CQC shows that maternity care is declining across the country. Abigail's death was not a one off.

“We lend our voices to the Maternity Safety Alliance and other bereaved parents in calling for a national inquiry to understand the true scale of failings in maternity care.”

Nisha Sharma, principal lawyer at Slater and Gordon, who represented the couple, said: “This is a heartbreak few of us can imagine, and to know things could have been so different if only the maternity staff had taken action sooner compounds this even further.

“If Katie had been given different advice, Abigail would have survived. That is a devastating reality.”

Giving her “full support” to calls for a national inquiry, she added: “The lives of babies and mothers are at risk until action is taken, and taking steps to prevent this absolutely cannot wait.”

University Hospitals Sussex NHS Foundation Trusts, which runs the maternity unit, said it had improved staffing levels and staff training, as well as increasing the monitoring and review of its telephone triage service.

Director of midwifery Emma Chambers said: “We extend our deepest condolences to Ms Fowler and Mr Miller, and their wider families – we understand the loss of their daughter has been absolutely heartbreaking. We are all so sorry for their loss.

“Since the death of Abigail, we have made several improvements to the way we triage our mums, and we are monitoring how effective these changes are very closely.

“The Maternity Team at UHSussex works hard to provide the best care to all of the families who use our service, and we are always seeking to improve wherever we can.”

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