Full Breakdown
Stillbirth at James Cook University Hospital Linked to Silent Cardiotocograph Alarm
By Drooid · · How we work
The fatal delivery
On May 16, 2023, newborn Hattie was delivered stillborn at James Cook University Hospital in Middlesbrough after staff failed to notice a paper jam in the cardiotocograph (CTG) monitor that was set to silent. The jam prevented the machine’s alarm from sounding, and the re-printed heart-rate trace later showed a pathological pattern that was not recognised before Hattie died at 9:43 p.m. An emergency caesarean section was performed only after an ultrasound revealed a dramatic slowdown in the fetal heart rate.
Inquiry findings
An independent investigation by the Healthcare Safety Investigation Branch (HSIB) concluded that the silent alarm setting on the electronic monitoring device directly contributed to the failure to detect the baby’s distress. The probe identified a series of procedural lapses, including staff attending to other infants on the ward and not promptly responding to the mother’s report of a paper jam. The report recommends changes to alarm settings and monitoring protocols to prevent similar incidents.
Impact on the family
Bethany Sowerby, 32, from Redcar, North Yorkshire, lost her fourth child. She now suffers from post-traumatic stress disorder and is receiving therapy and medication. Sowerby, who has three other children—Ella, Olivia and Oakley (2)—said the loss continues to dominate her daily life and that she feels compelled to speak out to avoid another family experiencing the same tragedy.
Official statements
A spokesperson for South Tees Hospitals NHS Foundation Trust expressed sincere condolences to the Sowerby family and noted that the matter is now in the hands of the parties’ lawyers, limiting further comment. Katy Daws, a specialist medical-negligence lawyer at Irwin Mitchell representing Sowerby, described the maternity experience as “extremely traumatic” and stressed the importance of learning lessons from the investigation to improve maternity safety.
Wider significance
The case has drawn attention during Baby Loss Awareness Week, observed annually from October 9 to 15, highlighting systemic risks in maternity monitoring. Stakeholders are calling for mandatory alarm-audibility settings and clearer escalation procedures to ensure fetal distress is promptly identified, aiming to safeguard future families from similar outcomes.