A Kent couple are campaigning to improve maternity care nationally after their “miracle” baby died following a three-hour delay in providing a potentially life-saving blood transfusion.

Sarah and Andrew Conroy’s baby, Kit, whom they had spent four years trying for, passed away at just six hours old on March 13, 2021.

Kit needed to be resuscitated after Sarah suffered a serious bleed, known as an antepartum haemorrhage, where the placenta separates from the womb, during labour.

It was the third time she had suffered significant bleeding, having first been admitted to London’s University Hospital Lewisham 36 weeks into her pregnancy.

Sarah, from Sevenoaks, said: “We had called Kit our little miracle. I had had surgery to remove fibroids, and despite years of trying, it felt like we were never going to have any joy.

“We had started to look into IVF and were due to have an initial appointment; however, the day before that meeting, I found out I was expecting.

“We were overjoyed that our dream of having a baby was coming true. We attended all the midwife and antenatal appointments and scans, and everything was fine.

“Then one day, I experienced significant bleeding. I was not in any pain, but the blood had soaked through my clothes onto the sofa.”

She had lost around 300 millilitres of blood at home and was diagnosed with a major antepartum haemorrhage.

The theatre box office manager was discharged from the hospital two days later, with doctors saying the cause of the bleeding was unknown.

Two weeks later, Sarah suffered a second episode of bleeding and again attended the hospital, where it was said to be old blood from her initial bleed.

She was booked in for a planned induction four days later when she was around 39 weeks pregnant.

At around 1.12pm on March 13, Sarah thought her waters had broken, but she had actually suffered another significant bleed.

A decision was made to deliver the baby by emergency caesarean, and Kit, who was starved of oxygen, was delivered at 1.28pm.

He took his first breath at nearly 17 minutes old, but instead of giving him an emergency blood transfusion during his resuscitation, medics did not administer blood until he was three hours old.

His condition deteriorated, and he died around six hours old in his dad’s arms.

Sarah, 39, said: “The day Kit was born should have been the happiest of our lives, but it turned to absolute despair.

“I do not think we will ever get over leaving the hospital and not taking Kit with us to start our new lives together.

“Kit will always be part of our family, and we will always love him. However, we will always believe he was badly let down.”

Following Kit’s death, the couple instructed specialist medical negligence lawyers at Irwin Mitchell to investigate the family’s care under Lewisham and Greenwich NHS Trust.

The trust admitted breaches of duty in that an emergency blood transfusion was needed, there was a delay in transfusing neonatal blood, and the volume of blood administered to Kit was less than required.

However, it stated that had he received a transfusion during resuscitation, he would have survived with significant brain injury, and if the blood transfusion had taken place after resuscitation, he would have died.

A Healthcare Safety Investigation Branch report into Kit’s death also found that Sarah’s antepartum haemorrhage was so significant that the bleeding had to have originated from the placenta.

Rather than doctors saying the cause of the initial bleed was unknown, it would have been appropriate to diagnose partial placental abruption.

As Sarah was approaching 37 weeks pregnant, there was an opportunity for her to remain in hospital and for her to be offered an induction of labour at 37 weeks, the report added.

However, during the legal case, the trust denied that the findings were a breach of duty and said it was not liable for Kit’s death.

It did agree to an undisclosed out-of-court settlement and has since confirmed that changes have been made to its practice.

A Lewisham and Greenwich NHS Trust spokesperson added: “We are deeply sorry for the circumstances surrounding the death of baby Kit and the profound impact of this on Sarah, Andrew, and their wider family.

“Following Kit’s death, the Health Services Investigation Branch conducted an independent review of the care we provided to both Sarah and Kit, and they offered recommendations to improve future practices.

“We developed an action plan to address these recommendations, which was shared with Sarah and Andrew. These changes have been fully implemented, and we are committed to continuing to listen and improve.”

Sarah and Andrew continue calling for lessons to be learned to ensure families receive the best standard of care.

Sarah said: “Parents need to trust their instincts and know it is OK to ask questions of medical staff to ensure they are happy with their care.

“Sadly, what happened to us was not an isolated incident, and you see and read too many stories about maternity care issues.

“No family want to find themselves in the position we have, but the least they deserve is for their voices to be heard.

“If by sharing our story we can help empower families to ask questions and improve care, then maybe Kit’s death will not have been totally in vain.”

Sarah and Andrew have since had two more children, Cooper, two, and Jude, eight months.