'I was blamed for my baby's death now NHS needs to change'

When Poppy Russell died shortly after birth, her parents were left bereft.

What followed made matters harder to bear - her mother was blamed for the death.

An inquest would later conclude that Poppy's death was preventable.

But instead of walking away from the trust that had failed them, Neil and Katie Russell are now working with it to bring compassionate care back into the NHS.

"We could have very easily been consumed by hate and anger and rage at what happened – and those feelings are still there," said Katie.

"But if no change comes from what happened to Poppy, then what's the point?"

Poppy Russell died in April 2021 at the Princess Royal Hospital in Telford.

She was just 12 hours old.

During her pregnancy her mother told midwives that she had tokophobia, a fear of natural birth and wanted a caesarean section.

Katie said she was repeatedly told however that she "couldn't just ask for a c-section."

When she went into labour, Katie was induced and then "we were left in a room for long periods of time where I had no care," she explained.

"Finally, when we got into the labour suite, I wasn't monitored appropriately and they missed signs that Poppy was in distress."

In a bitter irony, Poppy had to be delivered by emergency caesarean.

By then however, she had developed a hypoxic brain injury and died later the same day.

An inquest into her death found that had Poppy been born an hour earlier, she would have survived.

The Shrewsbury and Telford NHS Trust (SaTH), which ran the hospital, subsequently blamed Katie for her daughter's death.

They said she had refused foetal monitoring; the inquest concluded that was untrue.

"The trust left us in an appalling position," said Neil Russell.

"Not only were they found to have neglected our care, but in the months and years following, we uncovered that members of staff had tried to cover it up.

Losing your daughter is one thing, but then to find that there was a cavalcade of lies was almost as bad."

Following the inquest in 2023 the trust said: "We recognise there were failings in the care we provided and we are truly sorry."

It said the death of any baby was a "tragedy" and promised improvements to maternity services.

In March 2024, the couple had a meeting with the trust to discuss all that had happened.

From the discussions, Neil and Katie decided they needed to honour Poppy.

"The first conversations about Poppy's Promise were about being human," said Neil, 45.

"It spun from our treatment, and not being treated like human beings."

Poppy's Promise is based on four care principles:

• Compassion - showing kindness
• Acknowledgement - recognising a patient's feelings
• Respect - valuing their opinion
• Empowerment - involving patients in their care

"It's seeing the person, not the diagnosis. It's someone coming into a room holding your hand, someone acknowledging the fact that this is difficult for you," said Katie.

Even in the midst of her poor care at the time of her daughter's death, Katie, 41, vividly remembers one midwife who showed some compassion.

"She came in and said, 'how are you doing? I just want to hug you.'

"She sat with me and she cried with me and she said, 'this should never have happened,' and that will always stay with me because it's exactly what I needed at that point."

At the time of Poppy's death, SaTH was in the middle of a large maternity inquiry.

The review found that 201 babies and nine mothers might have survived with better care.

As part of its improvement programme, the trust is now rolling out Poppy's Promise to all 8,000 staff.

As well as reminding its existing employees of the principles of compassionate care, the trust has embedded a question about it into its recruitment processes.

The most important part of the training is "to remind me that we are here on a woman's journey, they are not on our journey," says Tasha Simmons, a midwifery ward manager at the trust.

"They don't need to know that I've answered three emergency bells this morning, that's not important to them.

"What's important is I'm fully present with them to support them in their experience, with kindness and compassion."

No-one starts a shift intending to provide care that is lacking in compassion.

The problem, say staff, is the pressure they are under - from the sheer number of people in Accident and Emergency to the complexity of many of the patients in hospital.

Remembering to treat each person with kindness in those circumstances can be a challenge, said Dr Adrian Walsh, an emergency medicine consultant at the Princess Royal Hospital.

There is a "high risk of emotional and compassion fatigue. Day in, day out we have a significant amount of competing demands," he said.

"But there's been some research done that actually demonstrates if people are treated with compassion and empathy, they have less complications, [their] outcomes are better."

Poppy's parents say that other NHS organisations and some universities have been in touch to explore whether they can incorporate Poppy's Promise into their teaching programme.

Their goal is to embed compassionate care throughout the health service.

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