'Perfect storm' of medical missteps cost newborn his life, Edmonton mother says

< warm>WARNING: This clause contains inside information of the dying of a baby.

With bright blue eyes and a shock of white hair, Huxley Bowes was born at Edmonton’s Grey Nuns Community Hospital on Dec. 9, 2017, but with no heartbeat.

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

Medical records, investigations by the regulatory agencies that govern Alberta doctors and nurses, and a formal apology from hospital administration point to cascading errors that allowed Huxley’s increasingly compromised condition to go untreated.

“We trusted implicitly, and that is something that 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 wide open.” 

A wrongful death lawsuit naming a doctor, three delivery nurses and Covenant Health, the agency that owns and operates the Grey Nuns Hospital, concluded in September following a formal dismissal in the Court of King’s Bench. 

Bowes said she decided to abandon the claim after a "mutually beneficial” out-of-court agreement was reached between the parties. 

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

In statements to the court, McCubbin denied the allegations, maintaining that the treatment provided to Bowes and her baby was "skillful, competent and careful," while Covenant Health and  the defendant nurses said Huxley's death was the tragic outcome of an "extremely complicated" labour, not neglectful care. 

Regulatory investigations, however, resulted in admissions of unprofessional conduct from all four medical professionals. 

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

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

The claim alleged that despite a high-risk pregnancy, medical staff ignored "clear signs" of fetal distress.

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

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

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

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

According to the statement of claim, she was administered medication to induce labour and was transferred into the care of McCubbin and her team.

The claim alleged that tracing scans that showed Huxley’s heartbeat had grown weak and sporadic were overlooked for hours. Bowes was administered oxytocin despite abnormal readings, and fetal heart monitors were removed during critical periods, the claim alleged. 

The suit aimed to hold Covenant Health vicariously liable for the alleged failings in medical care and the trauma Huxley’s parents said they had suffered.

“I told Julia, ‘When you're in that delivery room with me, I need you to be my wife, not the doctor,’” Bowes recounted. “And she did a really good job of it. We didn't watch the monitors.”

On Dec. 9, 2017, Huxley was delivered with forceps and brought to a warmer 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 removed from life-support. 

Medical documents show Huxley was suffering from a string of complications, including respiratory distress and cardiac failure. 

Bowes said that as life-support was removed, all the hopes she had for her son’s future gave way to grief and questions about what could have been done to save him.

Much of that night remains murky, cloaked by the shock and pain of the ordeal, but Bowes said she remembers some moments sharply, like seeing her baby’s face blue and pale, her wife’s voice breaking at her bedside, the brush of Huxley’s hair — soft like down — as they embraced him and said goodbye. 

“When those are the last images that you have of your baby, your perfect baby, it's not something that you can shake,” Bowes said. 

“It is imprinted in our memories. No parent should have to be left with the images and the things that we witnessed.” 

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

McCubbin, an Edmonton obstetrician, was sanctioned by the College of Physicians & Surgeons of Alberta in January 2022 after admitting that she had failed to provide the minimum level of expected care.

Key failures identified in that investigation included McCubbin's decision to prescribe Bowes oxytocin despite tracing that showed Huxley’s heart rate was abnormal, and her decision to blame those abnormal readings solely on the mother's medicated state. 

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

McCubbin, through her lawyer, and the CPSA tribunal agreed that the outcome resulted from a systemic breakdown in communication and care during a busy shift.

The tribunal heard McCubbin was so occupied with C-sections that night that she was only personally assessing patients when called to do so by her nurses, allowing the situation to escalate, with “catastrophic consequences.”

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

“The death of a child is tragic and unimaginable, and we extend our deepest sympathies,” the statement reads. 

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

In separate decisions issued in 2021, the College of Registered Nurses of Alberta found that Sylla, Kutz and Kenwell failed to properly assess or document the fetal heart rate. The tribunal noted that records were edited or altered after Huxley was born to make it appear as though the physician was more involved than she was.

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

Changes introduced by Covenant Health in the wake of Huxley’s death included the relocation of the hospital’s antepartum unit closer to delivery rooms, more stringent monitoring protocols for fetal health, and new measures aimed at improving communication between nurses, doctors and their patients in the labour and delivery room when cases grow critical.

In a November 2018 letter to Bowes, senior officials with Covenant Health said a systems review had been completed, prompting the operational changes being made.

“While we can never know if any of these recommendations would have prevented this tragic event, we believe that these actions will improve care for patients in the future,” the letter reads.

“We hope that our commitment to specific system improvements will give some measure of small comfort.” 

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

He cautioned, however, that Huxley’s death also underscores the urgent need for systemic reform to better protect patients from falling through the cracks in Alberta’s increasingly overburdened medical landscape when hospital resources are stretched to their limit. 

"This is a cautionary tale because you can see this chaos spreading,” Caulfield said. “And we know it's spreading across our entire health-care system.” 

For Bowes, the apology and knowledge that systemic improvements were made in Huxley’s name bring a modicum of relief. 

Inspired by his first toy — a stuffed bunny named Benedict with a tag that read “the meaning of life is to give life meaning”— Bowes said she hopes Huxley’s story serves as a catalyst for more change. 

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

“We chose to lean into life,” Bowes said, “and to give this little boy some purpose.”

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