Amber is a mother of mixed white and Black Caribbean ethnicity. Her story shows how a series of errors from early pregnancy contributed to the death of her twins, despite her working hard to access the care she knew she needed.
Amber shared her story with Sands as part of the Listening Project. Some of the details in her story may be upsetting to read or hear, please remember that we are here for you.
In 2021, Amber became pregnant. She had previously had surgery on her cervix and experienced two miscarriages, so the early pregnancy was a very anxious time for her and her partner. At an early scan, they were surprised and delighted to learn they were expecting twins.
At her first midwife appointment, Amber explained that she had had surgery on her cervix – she knew it was important for her midwife to have this information early in the pregnancy. The midwife told Amber that she would be looked after by a specialist twin doctor and referred for a scan to check the length of her cervix.
From 10 weeks, Amber repeatedly called her community midwives asking when this scan would take place. Each time, she was told she had been referred. At 12 weeks, she had not yet been given an appointment for a scan.
Amber was receiving conflicting information from her midwives about when the scan should take place. So at 17 weeks, she contacted the scan department directly. An urgent scan was arranged for two days later.
The scan showed that Amber’s cervix was short for a twin pregnancy, and an appointment was made for her to see a consultant obstetrician the next week. However, on the day of this appointment, Amber received a phone call to tell her the appointment would have to be rescheduled. It was arranged for a whole month later.
At 20 weeks, Amber’s scan showed that they were having a boy and a girl, and the babies were healthy and active.
At 22 weeks, the day before she was due to meet a twin doctor, Amber was assessed by a hospital doctor because she was feeling pains in her abdomen.
The next day, Amber went into labour and her daughter and son were born that day.
But there was nothing they could do. They were too small. And we wasn't in a hospital that could support them.
A review found that there were nine errors in Amber’s care.
Amber has since learnt that early errors in her notes led to her pregnancy being mis-categorised as ‘low risk’. Poor communication between departments, flawed electronic booking systems, and confusion about who was responsible for her care contributed to a series of cancellations and delays that prevented her and her babies from receiving the attention and care they needed.
Amber wonders if her treatment might have been different if she was from a different area or background. She believes there are differences in maternity care linked to ethnicity, shown by the fact that Black and Asian families are told to advocate for themselves more strongly.
If the NHS just listened to me. And just put my appointment through when I was constantly asking. If they had the notes there properly. I wouldn't have been treated that way. They neglected me. And all I get from it is, ‘I'm sorry.’
My memories is just movements. My memories is movements, and my memories is giving birth and saying goodbye. That's all I have. And I'm grieving what should have been, what could have been. I don't think I've ever felt pain like it. And I wouldn't wish it on anybody.
You can read the findings of the Listening Project and how we're using this to tackle inequalities in baby deaths and get involved in our campaigning on this issue.
Sands supports anyone who has been affected by the death of a baby before, during or shortly after birth. We also offer tailored support for Black and South Asian parents, family members and others following pregnancy loss or the death of a baby.