In 2009, Melissa was 5 or 6 weeks pregnant. She had a history of early miscarriages and was worried about this latest pregnancy. ‘I went to the doctor even though I was showing no signs of miscarrying and she said to go to the early pregnancy unit at the hospital. I had a scan the following day where they said that they couldn’t see anything but they asked me to come in again in 2 weeks’ time.’
In the intervening time, Melissa had been on holiday in the West of Ireland and had felt many of the signs of early pregnancy including sickness. She didn’t have that feeling on the 4 pregnancies that she had lost, but she did on the pregnancies of her 2 children, so she thought this was going to be okay. When she returned from holiday, Melissa attended the early pregnancy clinic at the hospital for the scheduled follow-up scan.
She could see on the scan that the foetal sac had gotten bigger, but the doctor looked at the midwife and just shook her head. The doctor said: ‘Sorry, but this pregnancy is not going to progress’. Because she was still only 8 weeks pregnant and had not displayed any of the signs of a miscarriage, Melissa asked again were they sure. They said that there was no heartbeat there and that they needed to discuss the options. ‘It was pretty devastating. Our options were that we could let nature take its course, they could give me tablets, or I could have a D&C. We said that we would go for the D&C because it was quick and it was clean and I had had it before. There wasn’t a slot available until 2 days later and Melissa says 'they told me to go home and gave me a drug...to be taken on the morning of the D&C, to open the neck of my womb and help it contract.‘
The following day Melissa still felt pregnant. On a friend’s advice, she went to a local GP for a second scan, and what a surprise when she got this scan! 'She [the GP] put the probe on my stomach and I could see a heartbeat, I could see it. My initial reaction was pure joy. And I said to her 'is that my baby’s heartbeat?' The GP wanted to check with another doctor 'He came in and flipped a switch on the machine, and all you could hear was' bump, bump, bump', of my baby’s heartbeat, and he said ‘I’m afraid the hospital are very wrong’'. They were so fortunate to have got the second opinion when they did. 'Luckily they [the hospital] didn’t have a slot on the Wednesday or Thursday or I would have had the D&C and I would never have known.'
Melissa’s husband rang the hospital to tell them that she would not be coming in for a D&C. 'They wanted to see me again so that they could clarify what had happened, and it was at that point then that I began to feel very nervous.' Melissa and her husband went to the hospital and she was seen by the doctor in charge of at-risk pregnancies. It did take her a while, but eventually, she said that she had found a good strong heartbeat. Melissa was given medication to help the pregnancy along and she was told to book herself in for her next appointment.
Melissa wasn't really satisfied. 'I said ‘is that it? I need to know what happened and why this happened.’ The doctor asked would Melissa like to speak to the Head of the Department, which she agreed to do. ‘They brought us into someone else’s office and apologised for what happened, and said that this had happened once before. I said that given that I had a history of miscarrying, should they not have given me another scan the following week instead of writing the baby off? They didn’t listen to me‘. Melissa also asked who would be looking after her for the remainder of her pregnancy and they asked a senior consultant to take over her care. 'I was assured that the original doctor would not be any part of my care'.
Melissa continued the pregnancy and was hospitalised twice before giving birth but there was no further mention of the incident by the hospital; its seriousness seemed not to have registered with the system. 'Nobody else spoke to me about what had happened. Nobody else came near me. At one point during the pregnancy, the doctor who had done the initial scan came along to do another scan! I didn’t believe that they would let her near me. We had to tell the senior staff what had happened and what we had been assured of. They had no knowledge of the incident and, incredibly, had to read through my notes!’
During that period, Melissa’s husband had been in touch with their solicitor and had informed him of the situation. In October 2009, they found out from the solicitor that the hospital was conducting an internal investigation but they had never discussed the case with Melissa. 'All throughout my pregnancy and my three hospital stays, not one member of management or staff spoke to me about my experience, which I found upsetting. I felt that if I hadn’t gone to my solicitor I would never know why I was misdiagnosed and what the hospital planned to do about it'. In January 2010 the hospital reported on my case. The hospital had found that the heart rate monitor was old and subjected to a heavy workload and that this had been known before Melissa’s misdiagnosis. In addition, the couch that was used in the examination was the wrong kind of couch, and the person who did the scan wasn’t qualified to do so. Despite these findings, nothing had been done as a result of the investigation. ‘They were still using that scanning machine 6 months after my case.’
Melissa was left feeling very unhappy and unsatisfied. 'When I found out all of this, I just felt that it was my duty to go public with it. I needed to go public with it and to let women know to trust their instincts in these matters. I didn’t believe that I was the only one that this had happened to. I needed changes put in place to prevent it from happening again.'
The story was covered in the press and on TV, and the publicity eventually led to the establishment of an independent enquiry covering all HSE maternity hospitals. This found 24 similar cases in the previous 5 years, with similar problems of faulty and outdated equipment, lack of training, lack of appropriate couches and a lack of appropriate services. The National Miscarriage Misdiagnosis Review was published and the HSE has been implementing its recommendations since through the Clinical Care Programme in Obstetrics and Gynaecology.
Publicising her story has helped to reduce the likelihood of similar incidents occurring again. Melissa also emphasises that it would have been both more proper and more effective for the hospital to have involved Melissa in its investigation in the first place, and to have communicated its results to her. She also feels that one of the root causes of the problems she encountered was that she wasn’t listened to during the initial scan. She feels that if she had been listened to, none of the subsequent problems would have occurred and that women need to be enabled to trust their own feelings in situations like the one she encountered.