A mother who lost her baby while giving birth said she was let down after staff at the hospital “just didn’t listen”.
Arthur Wyn Jones died at Glangwili Hospital in Carmarthen in March 2017.
His mother Kara Jones, 27, said she had been pleading for an early delivery because she knew something was wrong.
A report by Hywel Dda health board said “numerous missed opportunities to acknowledge the complexity of the pregnancy” were likely to have contributed to his death.
The young couple have now received financial compensation and hope to move on.
Living in Tre’r Ddol, Ceredigion, Ms Jones received her care during pregnancy at Bronglais Hospital in Abersytwyth.
But because of her diabetes, she and her partner Sam Penfold, 29, had to make regular visits to Glangwili Hospital, which has a specialist care unit.
It was there they began to ask questions about her care.
“We didn’t have a clue. No clue what was going to happen. Every day, we were going back, they were saying ‘we’re not sure about this, we’re not sure’,” she said.
In the internal report by Hywel Dda University Health Board, seen by Newyddion9, a catalogue of failings are listed that likely contributed to Arthur’s death.
Among these are numerous failures to act on abnormal scan findings, and a failure to expedite delivery.
Ms Jones said: “I remember having a dream when I was under the general [anaesthetic]. Sam and Arthur were sitting round a table. Arthur was saying ‘stay with dad’. Then Sam was saying ‘stay with me’. And then I had to choose what I wanted to do, if I wanted to die and go with him or stay with Sam.
“I remember Arthur saying ‘you’ll see me again anyway, I know you’ll see me again so stay with Dad for now’.
“So that’s what I did and I woke, and I asked Sam ‘is he ok’ – and Sam said ‘no he’s gone’.
“It’s just the hardest thing – waking up. You’re pregnant for nine months, and then you’re not pregnant. And that’s it – it’s gone.”
The couple had specific concerns regarding the behaviour of the consultant who was on call during that weekend, and following a formal complaint to the General Medical Council (GMC), Alan Treharne received a formal warning.
“This guy was the only consultant on call. And he came in, all the nurses were saying something was wrong. I really wanted him to help my little baby,” Ms Jones said.
“It’s obvious his intentions were to be a good person or he wouldn’t have wanted to be a doctor, so why couldn’t he help my baby?”
A GMC investigation came to the conclusion that Mr Treharne’s management of Ms Jones fell seriously below the standard expected of a reasonably competent consultant in obstetrics. No restrictions were placed on his practice.
Newyddion9 has contacted the solicitors representing Mr Treharne who did not provide any further comment.
Mandy Rayani, director of nursing, quality and patient experience at Hywel Dda health board, said she offered the board’s “sincere condolences and apologies for the distress experienced” by Ms Jones and her family.
“A thorough investigation was undertaken by the health board as well as the GMC. This resulted in a number of recommendations to change procedures and clinical pathways,” she said.
“Additional learning and training for the whole multidisciplinary team has taken place across the health board area. We wish to provide assurance that all of these recommendations have been implemented.”
Since then Kara has given birth to two children. Ralffi is 21 months, and Dyfi was born in April.
“It makes you realise how lucky you are to have babies when you lose one. But the two little ones, they’re amazing,” she said.
But Ms Jones and Mr Penfold are still unable to fully handle life.
Suffering from post-traumatic stress disorder, Ms Jones suffers constant nightmares and Mr Penfold accepts that his personality has completely changed.
‘Big and little brother’
“I’m not the same person. I did well at university, I was head boy, and played for Wales schoolboys’ football team,” he said.
“But now, I’m not comfortable around many people. I’m not sociable. I can’t imagine going to work.
“It’s not healthy at all.”
Looking to the future, the couple are in the process of setting up a trust in Arthur’s name.
The aim is to give children sporting opportunities, and the long term dream is to open a facility in Portugal.
With Ralffi and Dyfi keeping them busy, they’re moving forwards, but the family will always carry Arthur Wyn in their hearts.
“We tell Ralffi that he’s now a big and a little brother. And I don’t want to hide that from him, because if we hadn’t lost Arthur, we may not have had Ralffi and Dyfi.
“Things have worked out how they are, and maybe that’s how it was meant to be.”
Information and advice
If you or someone you know is struggling with issues raised by this story, find support through the BBC Action Line.
If you have been affected by stillbirth or neonatal death, the following organisations might be able to help: