A mum-to-be had taken the heartbreaking decision to abort one of her twins, which was suffering from restrictive growth. The condition raised the chances of stillbirth and put the healthy baby at risk.
But surgeons at Birmingham Women’s and Children’s NHS Foundation Trust targeted the healthy twin and both died.
The case is among 700 incidents in NHS hospitals in England where basic errors caused deaths.
Others, uncovered in a Freedom of Information Act survey, included patients falling from trolleys, being discharged too soon or not receiving correct tests or medications.
One unborn baby died after a delay in performing a vital heart scan at the Princess Alexandra Hospital Trust in Harlow, Essex.
North Bristol NHS Trust had a case where a patient died after a surgical mix-up meant the wrong section of the bowel was used to create a colostomy.
A patient at the same trust died following an overdose of beta-blocker medication.
The Northern Lincolnshire and Goole NHS Trust recorded that a patient considered at risk from deep vein thrombosis died after not being given anti-embolism stockings.
And at the West Suffolk NHS Trust, a patient was sent home from the emergency department having been told they were suffering flu, only to die later of sepsis.
A patient who was accidentally taken off an oxygen feed died at the Worcestershire Acute Hospitals NHS Trust. And Leeds and York
Partnership NHS Trust had a case of a patient who suffered from addictions taking their own life after a referral to a drugs and alcohol unit was turned down.
Referring to the twins’ deaths, a Royal College of Obstetricians and Gynaecologists spokesman said: “Selective fetal growth restriction is a condition that occurs in around 10 to 20 percent of twin pregnancies when one of the babies does not receive enough nourishment through the placenta to grow at a normal rate.
“In the most serious cases, selective termination can improve the survival chances of the normally grown fetus at the expense of the severely growth-restricted co-twin.
“However, all such procedures can carry an increased risk of early or total pregnancy loss.
“Parents who undergo selective terminations of twin pregnancies face agonising decisions and report feelings of anxiety, stress and emotional trauma. They must be supported by their clinical team both during and after their pregnancy.”
Dr Fiona Reynolds, chief medical officer at Birmingham Women’s and Children’s NHS Trust, said: “Sadly, during a highly specialised fetal procedure in 2019 that involved operating within the womb to separate and potentially save the life of a single twin that shared a placenta, a fatal error occurred.
“A full and comprehensive investigation was carried out swiftly after this tragic case and the findings were shared with the family, along with our sincere apologies and condolences.
“The outcome of that thorough review has led to a new protocol being developed to decrease the likelihood of such an incident happening again.”