Edmonton mother says ‘baffling storm’ of medical missteps cost newborn her life

WARNING: This article contains details of the death of a child.

Huxley Bowes, with bright blue eyes and white hair, was born at Gray Nuns Community Hospital in Edmonton on Dec. 9, 2017, but he had no heartbeat.

He was revived after 18 minutes, but died three days later from a myriad of catastrophic complications, including organ failure and hypoxic-ischemic encephalopathy, a severe brain injury caused by a lack of oxygen.

Now that the regulatory investigation and the wrongful death lawsuit alleging medical negligence have ended, Alicia Bowes, a nurse, said she and her wife, Julia Bowes, a surgeon, have decided to share the details of their son’s short life with CBC News in the hope they can help prevent future medical tragedies.

Documents obtained by CBC News show that Huxley’s death resulted in systemic changes to the operations of the Gray Nuns hospital – including new measures aimed at protecting patients against the particular dangers of complicated deliveries.

‘We trusted’

Elyseea bDue, who spoke to CBC News on behalf of the family, S.Help Huxley died due to a “perfect storm” of medical missteps.

“We trusted our colleagues and our health-care system,” he told CBC News. “He was in distress for hours.”

Medical records, investigations by the regulatory agencies that regulate Alberta’s doctors and nurses, and a formal apology from the hospital administration point to widespread errors that led to Huxley’s worsening condition not being treated.

“We trusted completely and that’s something I would caution any family against now,” Bowes said.

“You need to advocate for yourself and you need to go into that delivery room with eyes open.”

The wrongful death lawsuit that named a doctor, three delivery nurses and Covenant Health, the agency that owns and operates Gray Nuns Hospital, ended after a formal dismissal in the Court of King’s Bench in September.

Bowes said he decided to drop the claim after the parties reached a “mutually beneficial” out-of-court settlement.

Dr. Jacqueline McCubbin and Covenant Health, on behalf of nurses Erin Kutz, Mary Silla and Nicola Kenwell, filed statements of defense denying negligence in the case.

In statements to the court, McCubbin denied the allegations, saying that the treatment provided to Bowes and her baby was “skilled, competent and careful”, while Covenant Health and the defendant nurses said that Huxley’s death was the tragic result of an “extremely complicated” delivery, not negligent care.

However, the regulatory investigation resulted in admissions of unprofessional conduct by all four medical professionals.

Through their respective lawyers, each declined to comment on the allegations contained in the lawsuit and the regulatory bodies’ findings.

In a statement to CBC News, McCubbin’s lawyer said the civil case was resolved with Bowes agreeing to dismiss his claims. He described the couple’s allegations about the care provided to Huxley as “false and potentially abusive”.

‘IIt’s not something you can shake’

Originally filed in 2019, Bowes’ statement of claim alleged that multiple failures by the attending obstetrician, nurses, and hospital during labor and delivery led to delayed intervention and, ultimately, Huxley’s death.

The claim alleged that despite the high-risk pregnancy, the medical staff ignored “obvious signs” of fetal distress.

Alicia Bowes was 37 weeks pregnant when she arrived at the hospital on December 7, 2017.

Her pregnancy was considered complicated due to severe migraines and high blood pressure.

They had been trying to have a child through fertility treatments for years, and Bowes said they were “over the moon” with excitement.

She pictured bringing her baby home that night to a nursery painted with dark walls and a moving mobile.

According to the statement of claim, Bowes was given medication to induce labor and was transferred to the care of McCubbin and her team.

The claim alleges that tracing scans showed that Huxley’s heartbeat had become weak and sporadic and was ignored for hours. The claim alleges that Bowes was given oxytocin despite abnormal readings and that fetal heart monitors were removed during the critical period.

The purpose of the lawsuit was to hold Covenant Health vicariously liable for alleged failures in medical care and the trauma Huxley’s parents said he suffered.

“I said to Julia, ‘When you’re in that delivery room with me, I want you to be my wife, not a doctor,'” Bowes recalled. “And he did a really good job. We didn’t look at the monitors.”

On December 9, 2017, Huxley was delivered with forceps and brought to a warm table, flat and pale, with no detectable heartbeat.

He was transferred to the neonatal intensive care unit at the Royal Alexandra Hospital, where his condition rapidly deteriorated and he was eventually taken off life-support.

Medical documents show that Huxley was suffering from several complications, including respiratory distress and heart failure.

Bowes said that as soon as life support was removed, all her hopes for her son’s future turned to grief and questions about what could have been done to save him.

No parent should be left without the images and things we saw.– Alicia Bowes

Much of that night remains dark, clouded by the shock and pain of the ordeal, but Bowes said he remembers certain moments vividly, such as seeing his child’s face blue and pale, his wife’s breaking voice at the bedside, the brush of Huxley’s hair – as soft as down – as he hugged him and said goodbye.

“When those are the last pictures of your child, your ideal child, it’s not something you can shake off,” Bowes said.

“It’s seared into our memories. No parent should be deprived of the images and things we saw.”

doctor approved

All of the medical professionals named in Bowes’ lawsuit were investigated by their respective regulators, and ultimately admitted to unprofessional conduct during the treatment of Bowes and her unborn son.

McCubIn, an Edmonton obstetrician, It was cleared by the College of Physicians and Surgeons of Alberta in January 2022 after admitting it failed to provide the minimum level of care expected.

Major failings identified in that investigation included McCubbin’s decision to prescribe Bowes oxytocin even after discovering that Huxley’s heart rate was abnormal, and his decision to blame those abnormal readings solely on the mother’s medicinal condition.

The investigation also revealed that required fetal monitoring during critical stages of labor was missing or incomplete and that McCubbin had failed to adequately communicate with Bowes as the situation escalated.

McCubbin, through his lawyer and the CPSA tribunal, agreed that the outcome resulted from a Systemic breakdown in communication and care during busy shifts.

The tribunal heard that McCubbin was so busy having a C-section that night that she was only assessing patients individually when she was called upon by nurses to do so, escalating the situation with “catastrophic consequences”.

McCubbin was issued an official reprimand and ordered to undergo mandatory training.

In a statement to CBC News, the CPSA said it is important that physicians are held accountable when they do not perform as expected of them.

“The death of a child is tragic and unimaginable and we offer our deepest condolences,” the statement said.

“Although tragedies like this are rare, when they do occur, it is important that all parties learn from what happened and make changes to improve patient care and avoid such horrific situations in the future.”

In separate decisions issued in 2021, the College of Registered Nurses of Alberta found that Cilla, Kutz and Kenwell failed to properly assess or document the fetal heart rate. The tribunal said that records were edited or changed after Huxley’s birth to make it appear that the doctor was more involved than he was.

The College of Registered Nurses of Alberta and Covenant Health declined to comment for this story, citing privacy laws.

Changes made by Covenant Health after Huxley’s death included relocating the hospital’s prenatal unit closer to the delivery room, more stringent monitoring protocols, and new measures for fetal health. Improving communication between nurses, doctors and their patients in the labor and delivery rooms when cases become serious.

In a letter to Bowes in November 2018, senior Covenant Health officials said a review of the system had been completed, leading to operational changes.

“Although we may never know whether any of these recommendations would have prevented this tragic event, we believe that these actionsNS will improve pat careLiving in the future,” the letter reads.

“We hope that our commitment to specific system reforms will provide some relief.”

‘cautionary tale’

Timothy Caulfield, a University of Alberta professor who specializes in health law and policy, said the case is an example of when regulatory scrutiny results in tangible improvements in patient care.

However, he cautioned that Huxley’s death also underscores the urgent need for systemic reform to better protect patients from falling through the cracks in Alberta’s rapidly evolving medical landscape at a time when hospital resources have been stretched to their limits.

“It’s a cautionary tale because you can see this chaos unfolding,” Caulfield said. “And we know it’s spreading throughout our health care system.”

For Bowes, the apology and the knowledge that systemic reforms were carried out in Huxley’s name bring little solace.

Inspired by his first toy – a stuffed rabbit named Benedict with a tag that read “The meaning of life is to give meaning to life” – Bowes said he hoped Huxley’s story would serve as a catalyst for greater change.

Bowes said he and his wife cope with their grief by raising their daughters, now four and six, and remembering Huxley as an angel “who only knew love” during the precious few days spent with his family.

“We decided to move on in life and give this little boy some purpose,” Bowes said.