In 2009, Melissa was 5 or 6 weeks pregnant. Having had a history of early miscarriages, she was worried about this latest pregnancy. She had a scan at the early pregnancy unit at the hospital and was asked to come in again in 2 weeks’ time. Melissa was feeling like she did when she was pregnant with her 2 children, but not on the 4 pregnancies that she had lost, so she thought this was going to be OK. At the scheduled follow-up, she could see on the scan that the foetal sac had gotten bigger, but the doctor looked at the midwife and just shook her head, saying: ‘Sorry, but this pregnancy is not going to progress’. This was devastating for Melissa, but she still asked them were they sure. They said that there was no heartbeat and that they needed to discuss the options.
Melissa and her husband opted for a D&C, but there wasn’t a slot available until 2 days later. Melissa was sent home and given medication to take on the morning of the D&C. The following day she still felt pregnant. On a friend’s advice, she went to a local GP for a second scan, and what a surprise when she had this scan! ‘She [the GP] put the probe on my stomach and I could see a heartbeat…. all you could hear was’ bump, bump, bump’, of my baby’s heartbeat….!’ They were so fortunate -‘…luckily they didn’t have a slot on the Wednesday or Thursday or I would have had the D&C and I would never have known’.
When Melissa went back to the hospital they also managed to find a good strong heartbeat, although it did take some time. But Melissa wasn’t really satisfied, she ‘…needed to know what happened and why this happened…they brought us into an office and apologised…and said that this had happened once before…’ But Melissa says they didn’t listen to her when she asked…
‘…should they not have given another scan the following week instead of writing the baby off?’
However, they did assure Melissa that the doctor who carried out the first scan would not be involved in her care during the pregnancy. Melissa continued the pregnancy and was hospitalised twice before giving birth. But there was no further mention of the incident by the hospital; its seriousness seemed not to have registered with the system. ‘At one point during the pregnancy the doctor who had done the initial scan came along to do another scan! I didn’t believe that they would let her near me…we had to tell the senior staff what had happened and what we had been assured of. They had no knowledge of the incident and, incredibly, had to read through my notes!’
In January 2010 Melissa and her husband found out from their solicitor that the hospital had done an internal investigation and reported on it. But they had never discussed the case with Melissa. ‘I felt that if I hadn’t gone to my solicitor I would never know why I was misdiagnosed and what the hospital planned to do about it’. The hospital had found that, amongst other factors, the heart rate monitor was old and subjected to a heavy workload, and that this had been known before Melissa’s misdiagnosis. Despite these findings, nothing had been done as a result of the investigation. ‘They were still using that scanning machine 6 months after my case.’
Melissa was left feeling very unhappy and unsatisfied.’When I found out all of this, I just felt that it was my duty to go public with it. I needed to go public with it and to let women know to trust their instincts in these matters. I didn’t believe that I was the only one that this had happened to. I needed changes put in place to prevent it happening again’.
The story was covered in the press and on TV, and resulted in an independent enquiry covering all HSE maternity hospitals.This found 24 similar cases in the previous 5 years, with similar problems of faulty and outdated equipment, lack of training, lack of appropriate couches and a lack of appropriate services. The National Miscarriage Misdiagnosis Review was published and the HSE has been implementing its recommendations through the Clinical Care Programme in Obstetrics and Gynaecology. Publicising her story has helped to reduce the likelihood of similar incidents occurring again. But Melissa also emphasises that if she had just been listened to, none of her subsequent problems would have occurred.