With a tear rolling down her cheek, Stephanie Broadley holds her baby son Beau for the first and final time.
Beau had been stillborn minutes before the photograph was taken, after avoidable mistakes by midwives at the hospital in Grimsby.
The 28-year-old from North East Lincolnshire has released the picture to highlight what she says is the failure to learn from mistakes in maternity services and she called on health secretary Matt Hancock to take urgent action.
Ms Broadley had warned midwives that Beau was no longer moving before his birth in May 2018, but they did not listen and classed her as a low-risk case because she had requested a home birth
Speaking to The Independent Ms Broadley said: “Every time I look at that photograph I can see in my eyes the amount of pain I was experiencing in that moment. I want people in the hospital and the NHS to see how that devastated us, how it completely broke us, and to appreciate Beau was real. I’ve always said I want something good to come of what happened to us.
“As hard and as upsetting as it is for me to look at, it says everything that needs to be known about maternity failings in the UK. Too many families are going through this and things are not changing fast enough.
“I want Matt Hancock to look at this photograph, I’ve tried emailing him and never had a response.”
Ms Broadley and her husband Lee, 30, have backed The Independent’s campaign with charity Baby Lifeline for the reinstatement of the £8m maternity safety training fund which was scrapped after just one year.
She added: “It needs bringing back because they aren’t learning when things go wrong and the only way they are going to do that is with training.”
A serious incident investigation into Beau’s death, by the North Lincolnshire and Goole Trust, found the mention of a homebirth led staff suffering “task blindness” which meant guidelines weren’t followed when Stephanie’s waters broke at 37 weeks.
She was not given antibiotics to prevent infection and didn’t have her blood screened.
On three separate occasions Stephanie alerted midwives that she couldn’t feel movement during labour but no action was taken.
She said: “I wish I had been more forceful and loud. The problem is that you place your trust in the people who are there to care for you.
“When Beau was stillborn it was absolutely heartbreaking. I just held him in my arms and sobbed, and it is so difficult thinking back now because I feel like I let him down. I feel that I should have shouted out for him more.”
The investigation concluded an “over-optimistic” approach meant staff failed to appreciate the growing risk to Beau.
It said key decisions were made “without actually assessing the patient and not having the full history”. Midwives also failed to escalate concerns to doctors.
The couple, from Immingham, have also learned of another baby death 10 months before Beau. An incident report for that family, seen by The Independent, concludes maternity staff did not act when the mother’s blood pressure became raised during labour at Scunthorpe General Hospital.
The mother, who did not want to be named, was not reviewed by a doctor and the baby’s heartrate was not monitored as it should been with similar delayed actions by staff.
Ms Broadley said this investigation was completed five months before she went into labour with Beau saying: “Clearly nothing was learned across the trust from it.”
She added: “Health trusts are simply not learning lessons from mistakes and maternity staff continue not listening to mothers like myself when things are not right during pregnancy and labour.”
The trust has now admitted its failures in Beau’s care after a negligence case launched by law firm Hudgell Solicitors. It has yet to agree a settlement.
It is the latest maternity failing to emerge in the NHS as hundreds of potential poor cases are being investigated at the Shrewsbury and Telford Hospitals Trust and last week a new inquiry was launched into poor maternity care at the East Kent Hospitals University Trust.
The Healthcare Safety Investigation Branch has launched a national investigation into delays during labour which it said was causing deaths and stillbirths.
Former health secretary Jeremy Hunt, now chair of the health select committee, has also backed The Independent’s campaign and said he believes an inquiry into maternity safety nationally is needed.
Dr Peter Reading, chief executive at Northern Lincolnshire and Goole Trust, said: “I would like to offer my sincere condolences to Ms Broadley and her family for their tragic loss. We have carried out an investigation into the care Ms Broadley received but unfortunately as legal proceedings are still ongoing we are unable to comment further on this case.”
A Department of Health and Social Care spokesperson said: “We can never underestimate the agony of losing a baby and we are determined to make the NHS the safest place in the world to give birth. We’re committed to transforming maternity services as part the NHS long term plan, backed by an extra £33.9 billion a year by 2023-24.
“We are considering all options for central support for maternity training, as part of wider efforts to improve maternity safety.”