'If they'd listened, my baby wouldn't have died'

Tia's daughter Arabella died at 17 days old after a delayed emergency Caesarean at Torbay Hospital

"When they announced she'd passed away, I just broke down crying. I was screaming and I said, 'If they'd listened, this would never have happened'."

Tia's daughter Arabella died aged 17 days after a delayed emergency Caesarean at Torbay Hospital.

The 24-year-old and another mum, Megan, whose daughter Remi suffered a brain injury at birth after Megan was given the wrong medication at North Devon District Hospital, are calling for improvements to be made.

Both maternity units - like others in Devon - have been rated by the health regulator as requiring improvement.

Torbay Hospital and North Devon District Hospital (NDDH) have apologised to the women and said improvements have been made since their latest inspections by the Care Quality Commission (CQC) in November 2023.

'I'm angry every single day'

Arabella was born at Torbay Hospital but died aged 17 days

Tia lives in Torquay with her partner Blaze and her two children Dayton, seven, and three-year-old Storm.

She said her pregnancy with second child Arabella was "not easy" and she had been diagnosed with gestational diabetes and polyhydramnios - a condition that occurs during pregnancy when there is too much amniotic fluid.

In the latter stages of her pregnancy, she suffered episodes of reduced movements and said she grew more concerned each time she was checked out and sent home.

It was these issues that led to her being admitted to hospital for an induction at 37 weeks and three days in April 2020.

But the 24-year-old said the induction had been delayed by a handover.

"No-one really bothered with me," Tia said.

"The machine started beeping and that was her heart rate dropping, it was just delayed again.

"No-one rushed, no-one hurried and it was her heartbeat."

An investigation found issues with the way Arabella's heart rate had been monitored while Tia was being induced

A Healthcare Safety Investigation Branch (HSIB) report found issues with how Arabella's heart rate was monitored after Tia had been induced and said when medics realised there was a problem there had been a delay before starting an emergency Caesarean section.

"At the inquest they admitted that if she was born even an hour before she'd still be here perfectly healthy and fine," Tia said.

"I'm angry every single day. I think what makes me angry is this should never have happened.

"It makes me angry when my son asks about his sister and where she is and why isn't she here."

The HSIB report noted local policy guidelines on monitoring the baby's heart rate had not been followed.

The November 2023 CQC inspection found staff were still not consistently following "the trust's policies for 'fresh eyes' checks of cardiotocography (foetal heart rate) monitoring".

Tia said she wanted better training and more support for maternity staff

A spokesperson for Torbay and South Devon NHS Foundation Trust said: "We apologise unreservedly for the distress caused as a result of Arabella's tragic death in May 2020, and once again offer our sincere condolences to her family."

The trust said CQC inspectors had rated its clinical care as good, adding: "Many of the improvements they identified have been put in place including... strengthening the foetal monitoring training delivered to staff."

Tia now plans to raise money in Arabella's name for Kicks Count, a charity which raises awareness of reduced movements in pregnancy.

She said she wanted better training and more support for maternity staff and also urged women to have a voice in their care.

"Just because they're a doctor or a nurse, they don't necessarily know what's right for you," she said.

'I thought I was going to die'

Megan was given the wrong medication which caused her daughter to suffer a brain injury at birth

Another mother has spoken about her experience at a different Devon hospital.

While waiting for a Caesarean at North Devon District Hospital in February 2023, after suffering high and low blood pressure, Megan was given a drip which contained oxytocin rather than just saline.

Megan, who was 19 at the time and living in Barnstaple with her partner Cameron, knew something was wrong within minutes.

"The only thoughts running through my mind was obviously that I'd seen Remi's heart rate so, so low and I was just in excruciating pain," she said.

"I remember turning to Cameron and telling him, 'I don't think I'm going to make it out'."

The medication caused a placental abruption, which resulted in an emergency Caesarean and her daughter suffering a brain injury due to a lack of oxygen at birth.

Megan said: "We've had some ups and some downs, some very low downs but she's just an amazing little girl"

Remi has since been diagnosed with epilepsy and cerebral palsy.

"From day dot she has just proven that she is a fighter," said the 22-year-old mother, who now lives in Dorset.

"Don't get me wrong, we've had some ups and some downs, some very low downs but she's just an amazing little girl."

A HSIB investigation found the oxytocin infusion was left in the operating theatre unattended when staff were called to an emergency.

"This enabled the oxytocin infusion to be mistakenly collected and used in place of the prescribed intravenous fluids", investigators concluded, adding staff had overridden the hospital's electronic medication administration record system in order to give it to Megan.

The hospital has since admitted liability.

A spokesperson for Royal Devon University Healthcare NHS Foundation Trust said the hospital was "truly sorry to Megan, Remi and their loved ones for the failings they experienced".

They added: "We have accepted that we could and should have done better for them and we are working with them and their legal team to agree compensation to support Remi in the future."

Megan said: "It was nice to finally be able to say that it's fully confirmed that it was their mistake.

"Obviously you get the anger and all sorts of emotions behind it. I mean every day is like a rollercoaster - we have good days, we have really bad days. Our life's completely changed."

Maternity services reviewed

The safety of maternity services has been under scrutiny nationally.

The CQC carried out a review of all maternity services across England between 2022-2024 that had not been inspected prior to March 2021.

The review came after investigations from 2015 onwards into failings at specific trusts, including Morecombe Bay, Shrewsbury and Telford, and East Kent.

An independent review of maternity services at Nottingham University Hospitals NHS Trust, which is the largest inquiry of its kind in NHS history, is still ongoing.

The CQC's review of 131 NHS units highlighted issues with staffing, buildings, equipment and the way safety was managed, warning preventable harm was at risk of becoming "normalised".

It found almost half were rated as requires improvement (36%) or inadequate (12%), while only 4% of services were rated as outstanding and 48% were rated as good.

On safety, nearly two thirds were rated as either inadequate (18%) or requires improvement (47%).

All four of Devon's maternity units - Derriford, North Devon District Hospital, Royal Devon and Exeter and Torbay Hospital - were found to require improvement overall and in safety and leadership.

NDDH has repeatedly been rated as requires improvement over the last decade following CQC inspections in 2015, 2017, 2019 and the latest in 2023.

In 2020, following a BBC investigation into baby deaths at the maternity unit, then medical director Prof Adrian Harris, who took over the unit in 2018, said sweeping changes on the ward meant "progress" had been made, adding the unit was "completely different" from the "boardroom right down to the shop floor".

Torbay Hospital has also repeatedly failed to improve its CQC ratings having received requires improvement from its last three inspections in 2018, 2020 and 2023.

Abbie Aplin, the director of maternity reform for the Royal College of Midwives, said midwives were "really sad about the state of maternity services".

"They're not able to give the care they want to give to women every day, they work in fear most days that something will go wrong on their shift... which is completely unacceptable," she said.

Ms Aplin said recruitment and the retention of experienced staff was key.

"Sadly we're losing a lot of experienced midwives and that leaves junior midwives without the support they need and we need to make that better," she said.

NHS Devon's director of women Hannah Pugliese and chief nurse Penny Smith said they wanted to reassure women about maternity services in the county

Speaking to the BBC, Hannah Pugliese, who is director of women at NHS Devon Integrated Care Board (ICB), which commissions maternity services across Devon, said she wanted to reassure women.

"We've been able to respond really quickly to what the CQC has found and what we wouldn't want is for the women and the families in Devon to feel that they were going into maternity units that weren't safe because we've been able to make really rapid improvement in the areas that were identified," she said.

In relation to North Devon District Hospital, chief nurse Penny Smith said: "There were some really radical changes made to improve the resilience of the unit which has had really good impact and we need to sustain those impacts and carry them forward."

Asked if it was sustainable to have four maternity units in Devon or if care needed to be centralised, Ms Pugliese said: "Those discussions are always part of what we're considering for Devon because it's important that we understand both the needs of the rural population and the needs of those living in town."

Ms Pugliese added no changes would be made without consultation as the public's view was really important.

'Driving up standards'

A Department of Health and Social Care spokesperson said the NHS was "broken" and women were not "receiving the safe, personalised and compassionate maternity care they deserve".

"We are committed to driving up standards in healthcare through our Plan for Change," the spokesperson added.

"We will support trusts failing on maternity care to make rapid improvements and work closely with NHS England to train thousands more midwives to support women throughout their pregnancy and beyond."

Tia and Megan said they had shared their stories in the hope it would make a difference and other families would not have to go through what they had.

Megan said: "For something so tragic to go wrong, and I'm not the only one that's gone through something like this, what's it going to take to make a change?"

Tia added: "They can't keep letting this happen. One baby is bad enough."

If you have been affected by any of the issues raised in this story you can visit BBC Action Line.