A pregnant woman whose baby had died was sent home from hospital still carrying the child and told to make an appointment later in the week to give birth.
Danielle Brown, 31, from North Tyneside, had already been wrongly discharged despite having the life-threatening condition pre-eclampsia and had returned because she was still unwell.
After insisting on returning to the maternity unit, she was finally seen and doctors discovered her baby had died. Danielle would later describe the silence, the screen turned away from her, and turning to her partner to say: "I think she's gone."
Being sent home with Danielle carrying the baby was "horrible", her partner said, "lying in bed and holding that belly" knowing their baby was not alive.
The Newcastle Hospitals NHS Trust said it fully accepted "aspects of the care we provided fell short" and offered a "heartfelt apology".
Danielle and her 34-year-old partner Anthony Miller had been delighted to learn they were having a baby girl.
"I was just over the moon, I couldn't be happier," Anthony said.
They decided to call their daughter Maisie.
But, seven months into her pregnancy in February 2023, Danielle woke up feeling unwell. Her face was swollen, as were her hands and feet - all potential signs of pre-eclampsia, external, which can be life threatening to both mother and baby.
The couple went to the Northumbria Specialist Emergency Care Hospital in Cramlington, Northumberland, but medics found problems with Maisie's heart rate and told Danielle her baby needed to be delivered immediately via emergency caesarean section, external.
"Maisie's heart rate had dropped and a midwife ran in and said 'don't panic, but I need to pull the emergency cord - you're having your baby'," Danielle said.
The midwife told her space was being found for her at the Royal Victoria Infirmary (RVI) in Newcastle and doctors there "were going to do the section", she said.
She was transferred by ambulance but, once in Newcastle, Danielle did not have the operation and was instead put on a ward.
"A consultant came to see me and he said I am staying in hospital until Maisie was born," she said.
But, the following day, another doctor reviewed her and sent her home.
Within 24 hours, again feeling unwell, Danielle called the maternity unit and said she was told she probably had a stomach bug. But she insisted on being seen.
"When I finally had a scan, the screen was turned away and there was no sound," Danielle said. She remembers turning to her partner and saying: "I think she's gone."
Doctors were unable to find Maisie's heartbeat and they told Danielle her baby had died.
But, instead of delivering the baby, as she expected, Danielle was given a phone number, and sent home. She said they told her to "give us a call on Friday morning, and book a slot to come in and have Maisie".
At home the couple struggled to cope.
"It was horrible," Anthony said. "Lying in bed and holding that belly, and still being able to feel Maisie but knowing she wasn't alive."
The trust's executive director of nursing and midwifery, Ian Joy, said: "We fully accept that aspects of the care we provided fell short of the standards the family had every right to expect and offer a heartfelt apology for this.
Following a detailed review in 2023, we improved urgent assessment for women who come to our maternity services with unexpected symptoms or suspected complications and introduced quicker escalation procedures when there are concerns."
Legal executive Faisal Ali, from the law firm Irwin Mitchell, said pre‑eclampsia could be life‑threatening without appropriate care.
"What happened to Danielle and Maisie vividly highlights the human cost of care failings," he said.
"The trust admitted Danielle should not have been discharged on either the 14 or 15 of February 2023. Had she remained in hospital, monitoring would have shown the need to speed up delivery and Maisie would have been born alive."
An NHS England spokesperson said the failings in care were "unacceptable".
"Our deepest sympathies are with the family for their loss and the distress caused.
These failings in care are unacceptable and should never have happened," they said.
"Anyone experiencing the loss of a baby should be fully supported by a specialist maternity team so they can make choices about their care that are right for them."
