Tom recalls how he and Ewa watched the screen as they scanned. They didn't need anyone to tell them what happened. They could see a motionless ribcage. No movement. No heartbeat. In that moment, they knew they weren't going to get to meet their son Aubrey. As Baroness Amo publishes her Independent Investigation into Maternity and Neonatal Services final report, Tom shares how the couple continue to fight for justice for their son. They hope that one day, the care that failed him will be acknowledged, and there will be some form of accountability. 

Please be aware that Tom has chosen to include a picture of baby Aubrey's hand with his experience. 

"We were told that Aubrey's pregnancy was 'low risk’. What we didn't understand was that low risk, especially for first time pregnancies, means 'unknown risk', or the absence of previous known risk factors. There are many conditions that maternity services in England do not look for. Elements that were looked at were fundal height (which measured 50-80%) and urine tests (several of which were refused by labs but not repeated). 

At 36 weeks and one day pregnant, Ewa suffered from PPROM (rupture of membrane before 37 weeks). She was admitted and told that 'most women' with PPROM labour within 24 to 48 hours, and if not are sent home for expectant management. Ewa didn't see a consultant for 36 hours. She consistently mentioned that Aubrey’s movements were different since her waters broke - each time, she was given a CTG (heart rate monitor) which met 'criteria'. No other consideration, that we knew of, was given to changes of movement or general concerns. 

Ewa didn't labour - visiting was restricted to 1-6pm, and she was told that if she progressed outside this time I wouldn't be allowed in until she was ready to be admitted to the labour suite. An anxious first-time mother, under the specialist mental health midwife was told she'd have to go through the early stages of labour alone. Anxiety was never going to allow Ewa to labour in a hot, unfamiliar ward, alone. 

After finally seeing a consultant Ewa was discharged and given an appointment to return three days later for repeat bloods, and another CTG. We were told we were now 'high risk'. Asking 'how high-risk' we were told that there isn't really any grading - you are either low risk or not. 

We never made it to that appointment. 

Ewa started to get contractions two days later, widely spaced, but getting closer together through the day. In the evening Ewa’s mucus plug went. We called triage. Despite being high risk, we were told not to attend as her contractions were too far apart. 

About three hours later her contractions had increased to six to eight minutes. Triage told us it was time to attend. We grabbed our bags and drove in. We were going to meet Aubrey. 

Halfway into our 20-minute journey Ewa started to bleed. When we got to triage, we still had to wait. There was no urgency. Ewa was asked to change her pad, then sent back to the waiting room. When we were taken to the cubicle the midwife used the doppler to look for a heartbeat but there was nothing. This wasn't a midwife chasing the baby around struggling to get a clear reading, there was no heartbeat. There were no movement noises either. I had been sitting by Ewa’s feet due to the cramped cubicle; my instinct was to get to Ewa and hold her hand - neither the midwife or doppler were getting in the way. 

The midwife fetched a scanner and a doctor. Again, there didn't seem to be any urgency. We watched the screen as they scanned. We didn't need anyone to tell us. Everyone could see a motionless ribcage. No movement. No heartbeat. We weren't going to get to meet Aubrey. 

Nothing in any antenatal education, or NCT class prepares you for the fact that stillbirth is a realistic prospect. Rare yes, but not disappearingly rare. We don't talk about it. We're not warned about it. We don't want to scare mothers. 

Our thoughts went straight to 'get him out', but we were told we'd have to wait for doctors rounds to discuss options - because there are never doctors on labour suite are there? Fortunately Ewa laboured because labour had already started. We were able to use increased pain relief such as morphine. 

No one every prepares you for the fact that you might have to watch / help your wife give birth to your dead child. 

And that, at times, you might worry that you're losing them both. Because it's better not to scare the mothers that it doesn't happen than to do anything to help or prepare those that will have to go through the hardest thing imaginable. 

Aubrey was born at 1.19pm on 5th May 2022 - International day of the Midwife. Our beautiful baby boy weighing 2360g. Below the 5th centile rather than 50-80%. 

We don't talk about perinatal death. It's taboo. We all want to think that it won't happen to us. And, while rare, it might. You do not have to be the person with all the risk factors. It can happen to anyone. 0.4% seems low, 1 in 250 babies doesn't. We all know 250 people. 

In our minds, we knew that something wasn't right. 

We weren't eligible for a Healthcare Safety Investigation Branch (HSIB) investigation because Aubrey was 36 weeks five days and the cut-off is 37 weeks. The hospital classified Aubrey as an antepartum stillbirth (before labour has started), despite being delivered within 13 hours of demise, having attended due to contractions at six to eight minutes, and with '? Lab' on the triage whiteboard - HSIB only investigate intrapartum stillbirth (after labour has started). Aubrey, like every other stillborn baby in England (and Wales, but not Northern Ireland,) is not allowed any access to a Coroner, despite legislation to allow this having been passed in 2019. 

Aubrey was only allowed a PMRT (Perinatal Mortality Review Tool), undertaken by the Trust where the 'care' was given. 

After four years of fighting, Aubrey was allowed a repeat PMRT in 2026. This identified significant differences and gave worse 'gradings'. A PMRT cannot find fault and is completed behind closed doors. They can only grade care A, B, C or D. 

The trust where Aubrey died is reviewing all PMRTs from 2025 after the CQC found concerns that the reviews reflect. We know that our PMRT in 2022 was significantly changed when repeated in 2026. What about all the other parents whose 'reviews' might not have reflected what happened, or accounted for their perspective. 

We continue to fight for justice for Aubrey. 

We hope that one day, the care that failed him will be acknowledged, and there will be some form of accountability. We hope that gestational routes to investigation will be removed, and families of stillbirth will be able to access coronial oversight where there are concerns.