Midwives cost babies 'significant' chance of survival

Two midwives who failed to seek emergency care for two unwell babies, resulting in them “losing a significant chance of survival”, are facing the end of their careers.

Jasper White died in June 2019 and Margot Bowtell died in May 2020 after being delivered at the Cheltenham Birth Centre.

Midwives Hazel Williams and Lisa Land were on duty at both births and an investigation found they failed to have both babies promptly transferred to neonatal intensive care.

The Nursing and Midwifery Council (NMC) panel concluded on Tuesday that they had committed misconduct and their fitness to practice was impaired.

The panel further found that both midwives later falsified medical records in relation to Jasper.

Neither midwife was present or represented at the hearing.

The birth centre, part of the Gloucestershire Hospitals NHS Foundation Trust, allowed women with low-risk pregnancies to give birth away from a busy hospital.

But there were no emergency facilities and in the event of complications, patients should have been transferred to the Gloucestershire Royal Hospital, a 30-minute drive away.

Jasper’s health deteriorated within minutes of being born, but there was a 50-minute delay in transferring him to the neonatal unit in Gloucester and he died just 11 hours after being born.

The NMC panel found Ms Williams, the senior midwife, had failed in her duty to escalate the situation so Jasper could be transferred to a neonatal team.

It further found she had encouraged Ms Land to change medical notes describing his condition as “poor” to “good” three days after his death, and that she had added extra entries to his notes.

The three panel members found that Ms Land had also failed to escalate Jasper’s condition to the neonatal team and that she intended to mislead anyone reading the medical notes.

Eleven months later, Laura Bowtell experienced two episodes of bleeding during her labour in May 2020, but despite repeatedly asking to be transferred to hospital, this did not happen.

Her daughter Margot was not breathing when she was born and was rushed to hospital but she passed away three days later.

The NMC panel found Ms Williams failed to transfer Ms Bowtell to obstetric care despite her requests, and that she failed to notify the receiving hospital of Margot’s declining heart rate when the baby was transferred.

Ms Williams also exposed patients to harm or neglect by fostering a poor culture at the unit where learning from serious incidents was not transmitted to colleagues, the panel found.

The panel concluded that Ms Land was aware that Ms Bowtell was not suitable for midwifery-led care but did not arrange for her transfer to hospital.

It also found that she had recorded the presence of blood staining in the amniotic fluid and low maternal temperature, but would later dishonestly claim these notes were inaccurate.

Ms Land later sent WhatsApp messages to Ms Bowtell without clinical justification, which the panel found was found to be a breach of professional boundaries.

Panel chair Derek McFaull said Ms Williams and Ms Land had failed to uphold the standards of their profession, failed to treat their patients as individuals and failed in their duties of honesty.

He added that their actions had contributed to Jasper and Margot “losing a significance chance of survival”.

They had attempted to cover up their actions with “inaccurate or dishonest record keeping” and there had been an “increased risk of harm to patients due to staff not being up-to-date”, he said.

Mr McFaull said there had been no evidence of “insight or remorse” from either Ms Williams or Ms Land, or any understanding of the impact of their actions on the patients and their families.

He said that both could be liable to repeat their actions in the future.

The panel is due to determine what sanction the two midwives should face on Wednesday.

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