The baby girl who died at Blacktown Hospital months before Nigella

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This was published 8 months ago

The baby girl who died at Blacktown Hospital months before Nigella

By Kate Aubusson

The grieving parents of two babies who died at Blacktown Hospital are demanding to know how the tragedy that has caused their families unbearable pain could have been repeated.

Jennifer Fonua's daughter Thalia was one of the four babies to die unexpectedly at Blacktown Hospital in the space of 18 months. She was stillborn 14 months before the death of baby girl Nigella D'Souza in June 2020.

Jennifer Fonua with her five children and the teddy bear that contains her baby daughter Thalia's ashes. (L-R) Jennifer 5 , Elena 10 , Jennifer (mother), Natalie 12 , Xavier 7, Elenor 9.

Jennifer Fonua with her five children and the teddy bear that contains her baby daughter Thalia's ashes. (L-R) Jennifer 5 , Elena 10 , Jennifer (mother), Natalie 12 , Xavier 7, Elenor 9. Credit:Nick Moir

"When I read what happened to baby Nigella … I went into shock," Ms Fonua said. "I can't understand how something like this has happened again."

Nigella was stillborn after an almost three-hour delay performing an emergency caesarean section due to a failure to adequately assess cardiotocography (CTG) results that showed multiple and prolonged drops in her fetal heart rate.

Nigella's parents Praveen and Ashwitha D'Souza were shattered to learn another baby had died at Blacktown Hospital a year earlier.

"It makes us feel that there was a real opportunity for things to have been put right at Blacktown over a year before Nigella died," Mr D'Souza said.


More than 100 Blacktown Hospital nurses and midwives walked off the job for 24 hours this week, and 20 obstetricians threatened to resign if the Western Sydney Local Health District (WSLHD) did not address their grave and protracted concerns for patient safety, poor staffing and inadequate access to operating theatres for emergency c-sections.

Almost 20 months earlier, Ms Fonua was almost 38 weeks pregnant when she arrived at Blacktown Hospital.

It was just after 6pm on April 1, 2019 and she was scheduled for a caesarean three days later, but was admitted early to help manage her type 2 diabetes.

This would be her sixth caesarean, with her five older children waiting at home to meet their new sister.

Over the next four hours, the CTG strapped to Ms Fonua repeatedly showed signs that her baby's heart rate was in the "abnormal red zone", an investigation by independent specialists known as a root cause analysis (RCA) found.

At 11.32pm it was clear to staff that Ms Fonua needed an emergency caesarean, and 20 minutes later she was assigned "category 2", meaning her baby should be delivered within the hour, according to the RCA report.


At 12.30am Ms Fonua was wheeled to the anaesthetic bay just outside the operating theatre. Despite her abnormal fetal heart rate, the CTG had been removed in preparation for the surgery.


But at 1.10am Ms Fonua was bumped for another mother who also needed the theatre for an emergency caesarean. Her case was deemed to be more urgent, so Ms Fonua was taken back to the ward.

She recalls staff being told to reattach the CTG but she waited alone for at least 20 minutes, Ms Fonua said.

When the CTG was reattached, staff could not detect a fetal heartbeat.

"I said, 'Is the other lady's surgery over? Is she out of the operating room? Please just get my baby out now. Why are you waiting?'" Ms Fonua said.

Several doctors attempted to find a heartbeat, calling in a senior obstetrician to perform an ultrasound.


"[The obstetrician] said 'I am so sorry Mrs Fonua, you daughter does not have a heartbeat any more,' " Ms Fonua said.

Jennifer Fonua with photos of her stillborn daughter Thalia.

Jennifer Fonua with photos of her stillborn daughter Thalia.

It was 3.25am. More than two hours had lapsed since the one-hour window for her c-section had expired.

"I was lying on the operating table crying, begging them to let my partner be with me ... I didn't want to do this alone," Ms Fonua said.

At 4.40am her daughter Thalia was delivered via caesarean.

"There was silence. No cries. I knew it was true. She was gone," Ms Fonua said.

"I saw her and I just said, 'Please wake up, baby. Please wake up.' "


The independent specialists who conducted the RCA concluded that had the CTG been attached to Ms Fonua when she was in the anaesthetic bay, her baby's deteriorating condition would have been detected, and staff could have called in a second operating team.

"There was a failure to detect worsening fetal condition because of the absence of continuous CTG monitoring," the RCA report said.


This was the "root cause" of Thalia's death, the report said.

It also noted Ms Fonua had not been transferred to the acute maternity service because there were no beds available.

A paediatric team tried to resuscitate Thalia for 16 minutes before declaring time of death, despite the obstetrics team having confirmed "fetal death in utero".

The RCA team said the failure in communication between the obstetrics and paediatrics team added to the distress of Ms Fonua, Thalia's father and staff.


Though it did not alter the outcome, it raised "concern that such miscommunication may lead to adverse outcomes in future emergencies".

Libby Brookes, NSW head of medical negligence at Maurice Blackburn Lawyers said it was inexplicable why steps weren't taken to deliver Ms Fonua's baby within the hour in accordance with the obstetrician's instructions after it was detected she was in distress.

"It's really disappointing that CTG monitoring of the baby's heart rate was ceased while waiting for a theatre," Ms Brookes said.

"The hospital's investigation into this baby girl's death rightly found that a second theatre team could and should have been called in to urgently deliver her and this contributed to the avoidable death," she said.

The RCA made several recommendations, including a review of the hospital's ability to ensure continuous fetal monitoring of all cases where there is a suspicion that a fetus is compromised, and a review of compliance with CTG education.

Nigella's father Mr D'Souza said, "We feel that the people who investigated that baby girl's death in April 2019 then failed to improve communication and practices at Blacktown Hospital.

"They failed to make the hospital safer, they failed us and they failed Nigella," he said.


After Ms Fonua was discharged, Blacktown Hospital management asked her to share her feedback with them so they could make any necessary improvements.

"I told them, 'Please make sure this never happens to another baby again.' "

Ms Fonua, her partner and five children have found comfort in each other as they continue to grieve.

"The heartache and pain and suffering we are experiencing is horrible," Ms Fonua said. "We don't want any more families to go through this."

A spokesperson for Western Sydney Local Health District said any unexpected death was taken very seriously.

"While NSW Health does not comment on individual cases, the district follows a rigorous process to ensure we identify, investigate and manage adverse events," the spokesperson said.

"If a root cause analysis identifies recommendations for action, [WSLHD] has a process that ensures the appropriate staff members are aware of them, and tracks all recommendations until implementation has occurred."

RCA reports are also submitted to the Ministry of Health and Clinical Excellence Commission "to ensure escalation and awareness of any issues and learnings identified".

NSW Health Minister Brad Hazzard has requested every case of newborn deaths in WSLHD be brought to his attention, regardless of the circumstances.

Last Wednesday, another baby was stillborn at Blacktown Hospital, sparking another RCA, but it is too early to know whether this tragedy was potentially avoidable.

On Monday, the WSLHD executive agreed to set up a dedicated operating theatre for the obstetrics after Mr Hazzard intervened to end the rift between the executive and the obstetricians threatening to resign.

The local health district also committed to implementing the recommendations of a review of obstetrics services, led by the NSW chief obstetrician, ordered by Mr Hazzard in response to Nigella's case.

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