Theo's Story...

After 14 years of trying to start a family Lee and I found out I was pregnant. We were overjoyed by our news and couldn’t wait to tell our immediate family. Our little baby was finally coming, our dream was becoming a reality, our families overjoyed and all of us extremely excited.

During the first trimester I became very sick, so much so I had to be medicated for the duration of the pregnancy but otherwise our little baby was doing well. We had regular check ups and were very excited and busy with all the preparations that come from being new parents. 

At the 20 week scan we were told we were having a girl, a daughter – the joy we felt was immense but we had a scare because there was very little amniotic fluid around the baby, just 1.5cm at it’s deepest part, they said this was Oligohydramnios. Our baby was breech and the position our baby was in they couldn’t find one of the kidneys. We were terrified as to what this meant and were referred to the amazing team at St Thomas’s Hospital in London where a Foetal MRI was performed. 

A couple of weeks after the MRI we went back to Medway Maritime Hospital for another scan and for the results of the MRI. The kidneys were found our baby was perfect just a little on the small side which was no surprise as both of us are very short as is most of our family. Whilst having an ultrasound they asked if we knew the gender and we told them yes, we’d been told we were expecting a little girl. They were shocked and said our baby was definitely not a girl, it’s a boy! A boy – a Son our perfect little man. Lee literally jumped out of his chair with joy and excitement. We were advised because of the size of our Son we would have checks every 2-3 weeks to check for Foetal Growth Restriction. However, there was good news the amniotic fluid was improving and over the course of the next few scans it had become a normal amount of fluid. 

We continued to attend each of our appointments together, did everything we were advised but our little Theo was still a little small but they weren’t concerned. It was decided that they would deliver him early by caesarean section at 37 weeks as he would grow a little faster once he was out in the world. 

As the weeks went by we chose a name – Theo, it meant God’s Gift and to us he was, he was conceived around my Birthday and after all those years of trying I very much viewed him as the best present I had ever or could ever receive. We chose his full name Theo Sam Lee Pepper – Sam to honour my late uncle as it was his initials and Lee after Theo’s Daddy. His nickname was our little Son-Shine.

At 36 weeks I had my final appointment with the community midwife, it was 6th October 2023. The community midwife performed all of the usual checks, and did a doppler check to check on little mans heartbeat. At the end of the appointment she couldn’t stop praising us because we were ‘model patients’ attending each appointment, doing as we were told, I’d lost 10kg during my pregnancy and our baby Theo was in her words ‘perfect’, - oh he really was!

We went home that afternoon and my Mum and youngest Sister had surprised me with a baby shower – I had never thought I would be lucky enough to have one and they had gone to such a wonderful effort of making everything so beautiful for me and to help welcome our Son. There was the usual shenanigans, lovely food, presents and laughter – I went to bed that night so happy it truly was a perfect day…

The following morning was a Saturday we woke up and were starting to get things ready for the hospital, getting the last few things at home prepared for Theo’s arrival we knew it was imminent just a few short days away. In the evening I went to the toilet and lost a yellow fluid. I immediately shouted for Lee to bring me my phone so I could take a photo of the fluid I had lost in case the hospital needed to see it. I knew something wasn’t right. At first the fluid was like a jelly but then as I kept wiping it became more like water. I cleaned myself up and went into the front room and rang my Mum to see what I should do, she told me to ring the hospital so I called the ‘Call The Midwife’ helpline number. The entire call lasted just 2 minutes and 45 seconds…

I explained to the midwife on the phone about the fluid I had lost I explained about the earlier diagnosis of Oligohydramnios and that I’d been regularly monitored. I told her I was a first time Mum and scared and that I had a photo of the fluid I had lost. I asked if I could attend the hospital to be checked as I was scared and needed some reassurance. She told me “Not to be silly, it sounds like a show and that they wouldn’t do anything for a show so I would be sent home.” I then told her I had a photo of what I had lost and that I know you aren’t meant to Google symptoms but we all do (and I giggled at this nervously), I told her that it didn’t look like what Google was saying a show was and pleaded with her to come up, explaining that I lived about 40 minutes from the hospital so it would take me some time to get there as my Mum would have to come and get me and she lives 45 minutes away from us. She replied “I don’t need to see a picture (very arrogantly and uncaring) it’s a show and we won’t see you if you come up to the hospital we will refuse to see you and turn you away.” I asked her what I should do she said “monitor it for at least 24 hours, put a pad on and only call back if you have a sudden gush of fluid, severe pain or blood loss” I had none of these. Not once during the phone call did she take my name or date of birth and didn’t give me her name either.  I listened to her advice got off the phone and rang my Mum to tell her what had been said. She was surprised they didn’t want to see me but we both agreed it was what I was advised.

On the Sunday I could still feel Theo moving but I was tired so had a lazy day, the fluid had slowed right down almost like a discharge so I had assumed the midwife was right. I went to bed and when I woke on Monday 9th October I said to Lee that I wasn’t sure I’d felt Theo moving in the night, he told me he thought he had felt him wriggling. I tried to have a cold sweet drink to get him to move. We also used to love a couple of pieces of music that would always get him kicking these were Rappers Delight by the Sugar Hill Gang and the current Formula 1 Theme song from the Game and Sky Sports. I drank my drink and played the music but no movement – I knew something was terribly wrong. 

Straight away I phoned my Mum and got her to leave home, I then rang the ‘Call The Midwife’ number again and spoke to a lovely midwife – I told her what had happened including my previous call on the Saturday evening. Straight away she asked me for my name and date of birth and told me she wanted us to come up to check on Theo. I asked if it would be advisable to bring my hospital bag because they wanted to deliver at 37 weeks and we were only days from this. She said it would be advisable. My Mum arrived within around 40 minutes and we left straight away to head towards Medway Hospital. When we arrived we went to the Maternity Care Unit – they took me straight in and asked if they could check my pad. Whilst a midwife went to check it, another performed a doppler scan – at this point we had no idea there was a problem other than still no movement. Within moments the first midwife came running back and said “did you know your waters have broken we will take you up for delivery”. Lee went to tell my Mum who was waiting in the waiting room and I got wheeled in a wheelchair up to the 4th floor to the delivery suite. We got taken to a room where a scan was performed and then the worst happened… there was no heartbeat, our little boy was gone! 

We broke, how can this be? He was perfect just a few days ago, he was coming and now he has gone! Our worlds collapsed there and then, a gaping void that can never be filled consumed us. I was given a tablet to take to help bring on contractions to start the process of delivering Theo but the tablet didn’t work. I had to wait 24 hours to have a second dose, this time the tablets placed behind my cervix. 

Around 7:30pm on Tuesday 10th my waters broke, and delivery had started. I begged and pleaded with the hospital for a caesarean as I was terrified of delivering a breech baby, I had been told the whole way through the pregnancy that it was going to be a c-section so to now have a vaginal birth wasn’t something I was prepared for and wasn’t sure I could do but the hospital staff were adamant that a vaginal birth was a better option for recovery reasons and a scar would be a permanent reminder…as if I wouldn’t already have that! Immediately after Theo was born the consultant said “It’s ok love you’ll be here again soon with another one, you can try again” Like Theo didn’t matter...

At 01:38 Wednesday 11th October baby Theo was delivered weighing 4lb 11oz he was just 46cm in length but the most perfect little boy. We adored him, and for a few hours it was like he was really here, not dead but there in the room with us. We took pictures and I had messaged everyone close to us about him as though he really was. We went to bed and put Theo in a cold cot which was from an amazing charity, Abigail’s Footsteps.

We awoke around 7am and it hit us, our boy was there but not in the way we had dreamed. Our life felt like it was broken, and it was. Around 8:30am the intrapartum matron came round and started asking us questions. We explained everything to her and she went away. She came back to our room several times in a short period asking us the same questions so we asked her why. She explained “The calls to Call The Midwife aren’t recorded and our call logs are showing a different time to what you are saying you called” I then got my phone out and showed her my call logs and then emailed her a screenshot of them as proof! I asked why they were saying a different time and she explained the calls are set to American times… We asked for an investigation to be launched which it was. We also met a ‘Bereavement Specialist’ who was so cold it was like a business meeting – no empathy, no care.

Later that day we got moved to a small flat within the hospital donated by Abigail’s Footsteps enabling bereaved families to spend time and make memories with their babies. If it wasn’t for this beautiful space we would have had just hours with him. Thursday came and we met a second bereavement specialist who was very helpful to us and kind, she took some photos of us with Theo and helped us create some very precious memories.

By the Friday we knew we had to leave, Theo had started changing and needed to go for his post mortem at Great Ormond Street. We hadn’t slept since the Sunday night so were advised to get an emergency prescription for sleeping tablets. The tablets weren’t done so the following day I spoke to my GP again who had no idea what had happened to Theo he in fact at first said he couldn’t give them to me because I was pregnant, I had to explain it to him. He was mortified – he hadn’t received any of my notes. By the time we had left the hospital we had heard from 11 different staff members about trying again and being back soon.

After we left the hospital we received little to no support whatsoever, we weren’t told when Theo left the hospital to go for post mortem or when he returned. They even sent the wrong forms to the funeral director for his cremation. We had asked over 18 times to see the mental health team and to see a counsellor we were told to wait. We sent a letter of complaint to PALS and before we had even had a letter of acknowledgement the investigator had rung us and told us word for word what was in it! 

By the time I went for my 6 week postpartum check up with my GP he still hadn’t received any of my medical records from during my pregnancy or notice about Theo. He was disgusted. In December we were told Theo’s post mortem results were back the bereavement specialist read them on the phone and told us it was quick and he wouldn’t have suffered and that we needed to come in for the results with the professor, we attended and they put us in a very festively decorated room with a large ‘Merry Christmas’ written on the whiteboard. They explained the results which was that Theo had a small blockage in the cord and he tried to break the waters. He ruptured them in the wrong place, behind him so he was gasping for air. I asked whether he suffered the professor at the hospital told us it wasn’t quick our boy was gasping, he suffocated and then drowned with fluid in his lungs. There were signs of meconium in the fluid in his lungs. I asked how long he suffered for he explained it would have started when I started to lose the fluid on the Saturday until I couldn’t feel him anymore – that was over 24 hours later! When I asked if there was a chance to save him he told me there was, that if we had got up to the hospital even by late on the Sunday they would have performed an emergency c-section and the likelihood is Theo would be here alive today! 

We broke and asked him why the midwife told us we would be refused to be seen he said that was wrong of her and they wouldn’t refuse to see me, but her advice was what we had listened to and he explained that was the correct thing to do but her advice was terribly wrong. He then explained he couldn’t speak about the investigation because that day was about the post mortem results so had to wait for a second meeting regarding the investigation. We then had to go through Christmas – one that was meant to be with our miracle baby and instead was our worst nightmare. On top of losing our Son we lost my Nan, grief was surrounding us and we very much felt like we couldn’t cope. In January we had to leave our home for 2 months as it’s a holiday park and it closes so on top of everything we felt like we lost our home too. 

January 8th 2024 came and it was time to go for the results of the investigation we travelled about an hour to go back to the hospital that killed our son, back to where the nightmare began. They put us and our family in a small room and couldn’t even look at us. We were given a 12 page report to read through which stated several wrong things: 

• They stated Polyhydramnios instead of Oligohydramnios

• They Said I’d made a call on the Sunday and spoke to the same midwife yet they had a copy of my call logs – definitely no call then on the timeline of events in the back there was no mention of supposed call.

• They said I’d seen the matron on the Sunday – Theo wasn’t born until the Wednesday Theo was in the cold cot whilst speaking to her – she noted how lovely he was!

Then we got to the part where the midwife gave her reasons for her actions these were:

• She was preoccupied by a previous call from another patient

• She hadn’t had a break all day

• She didn’t want to burden the hospital – Burden a hospital, with a life? That’s what they are there for what they are paid to do!

They listed ‘multiple failures’ on her part from failing to access my medical record, take my name, or record anything on the system. We asked them their intended actions with her they told us “We have a no blame culture its not one its all” we told them then they should all lose their jobs. They told us they weren’t even going to give her a disciplinary!

We asked why we had received such a lack of care, they said it was ‘optimum practice to wait’ and when I asked why Theo hadn’t mattered to them it took them several moments to respond and when they did ‘oh umm yes of course he mattered’. I asked if the midwife had even tried to apologise they paused for what seemed about a minute and then suddenly ‘oh well yes er of course she has but um that’s not the sort of thing we would umm pass on’ I replied well what is? 

The whole way through the meeting they refused to answer any of our questions or just replied with a very condescending hmmm noise. We left the hospital, they didn’t thank us for coming just pointed and said ‘exits that way’. Once home we knew something had to be done, we are terrified she will be allowed to do it again. We got in contact with the press and set up a petition for Justice for Theo. We decided to launch a charity in loving memory of our son and to ensure that no one has to go through something so heart-breaking ever again. To ensure that if something like this happens people are supported. 

Multiple failures, no support and a family broken – a very precious little life lost and nothing is done – this is why we want to ensure that legislation is changed for the standard of care. To ensure that if people are found to not be doing their jobs correctly that there is always action taken especially if they cause serious injury, harm or death. We want to ensure that if you are a bereavement specialist you are unbiased and there to support the family in the very best way you can. 

After the press release we have been contacted by various people with their utterly heart-breaking stories from up and down the country and even from the same hospital. The impact of these losses are so incredibly hard and we cannot understand why more isn’t being done to protect those little lives and to support the families whose lives have been destroyed forever.