I wanted to share my experience at the hospital where I gave birth to Autumn. There were a number of things that were disturbing, especially after everything that happened with her death. We do intend to formally write to the hospital and the Ministry of Health with our complaints, but we are waiting for the autopsy report to come in first…just in case there is a cause to suspect negligence. In that case, obviously, we would be pursuing a different course of action.
The first thing was a rather small detail. My midwife wasn’t able to find a pillow for my bed on the L&D floor. She had to improvise by stuffing a few bed sheets into a pillowcase to Macgyver a pillow for me. I don’t know whether this is a common occurrence at hospitals….but not something I was really pleased with because it really wasn’t that comfortable.
The second thing was definitely a big thing for me. The hospital I chose was not the closest to us. In fact, it was pretty out of the way, but I chose it because of the option to have a water birth. The jacuzzis were located in private rooms across the hall from the birthing suites (at the time of the delivery the L&D floor was undergoing renovations to move the tubs into the birthing suites). My plan was to use the tub for pain management for as long as possible instead of going straight for an epidural. When my midwife went to prepare the tub she found that it hadn’t been cleaned from it’s prior use. She had to request the tub be cleaned, which was done by the hospital, but then she realized that there was no hot water. So using the tub was out completely, which was the whole reason I chose that hospital.
Things get a little hazy here because of the shock of actually delivering Autumn and the subsequent events. My midwife called the on-call paediatrician and two NICU nurses into the birthing suite just before delivery because of the presence of meconium in the amniotic fluid (this is common protocol when they see meconium). We overheard some discussion among them that the machine attached to the wall above the warmer may not have been working properly. Basically they had had issues with that machine in the past. Once Autumn was on the warmer they brought in a mobile machine to measure her blood oxygen levels, however I definitely heard them say again that they weren’t sure that machine was working. It was at that point that they decided to take Autumn to the NICU for further assessment.
Once I was in the NICU with Alden and Autumn, which was about an hour after her birth, I witnessed complete chaos while the hospital staff worked on her. They couldn’t find things that they needed, nobody was taking notes, and everything just seemed very disorganized. I realize that they were dealing with an emergency and some chaos is probably pretty normal, but there was a definite difference between the hospital staff and the SickKids staff (once SickKids arrived). When the SickKids Team took over Autumn’s care there was a complete change in the room’s atmosphere. I actually felt a sense of relief watching them work, calmly and professionally. We could also sense that there was some frustration on the part of SickKids towards the hospital staff. We observed the hospital staff being asked by the SickKids Team who was responsible for recording notes, and watched as the hospital staff scrambled to find paper and pen to start recording. The hospital staff could not confirm how much she weighed and had difficulty accurately relaying what efforts had already been made to stabilize Autumn. We observed one paediatric nurse in particular who appeared defensive when asked by the SickKids team what had been done prior to their arrival. We also witnessed one of the nurses spill blood on the floor and chair as she was scrambling to provide plasma for the SickKids team, and they could not find a specific item that SickKids had requested and were scrambling and searching through drawers and cupboards to no avail.
Out of everything that happened that night, watching the apparent inexperience of the hospital staff managing my daughter’s condition was one of the most traumatizing. I re-lived those moments over and over again for months. It kept me up at night and I wonder whether I suffer from a form of PTSD as a result.
To clarify, the hospital is supposed to be a level II nursery, with the resources and knowledge to manage relatively sick infants, located in a major metropolitan city in a first world country.
The whole incident with Autumn in the NICU took place in front of all the other parents who had infants in the nursery. From her crashing on the table to them telling us that she was not going to make it, all the other parents were witness to it. Not only did it not allow for us to have privacy during the worst moment of our lives, but I can only imagine how those other parents felt being witness to the death of another infant while their own child is sick enough to be in the NICU.
Instead of having the opportunity to bring Autumn back to our private room to say goodbye, we were led into what is essentially a storage closet with a table and chairs to say our goodbye. Rather than allowing us that quiet time to say goodbye, the paediatrician came in to give her condolences but also to gather information about any family history that could have contributed to Autumn’s death. This happened while I was holding my daughter in the final few minutes of her life, and it robbed me of that precious time with her.
Finally, someone took pictures of Autumn for us after we left. There seemed to be no effort made to make the pictures something we would actually want to look at. The tubes were still attached to her, and to be honest, she looks deader than dead. Those images are traumatizing and I’ve since given them to my father to hold because I don’t want Alden to see them. I don’t understand why they couldn’t have made some effort to clean her up, or called a service like Now I Lay Me Down To Sleep.
The final nail in the coffin that something needs to change happened about six weeks after her death when I got a letter in the mail from the Ontario Government reminding me that I hadn’t registered the birth of my newborn. Apparently there is no procedure in place to notify the appropriate institutions that a death has occurred to save the parents the trauma of having to record their dead infant’s birth with the government. I can’t describe how hard it was to answer all the questions about her birth, and I should never have had to do that. No loss parent should have to do that.
If there is anything good that comes from Autumn’s death it will be that I will fight to make changes happen, with the hospital in particular, so that no other parent has to experience such a clusterfuck.