- Infant deaths at NHS Trust
- Midwives’ inaction, investigation underway
- Trust acknowledges, learns from mistakes
Preventable infant deaths have occurred at Gloucestershire Hospitals NHS Trust, according to midwives, due to deficient staffing levels and a negative organisational culture.
A newborn infant perished as a result of the Trust’s inaction regarding two staff members.
The Trust expresses remorse for its shortcomings and pledges to learn from its mistakes.
Twelve months before the death of another infant, colleagues at the Cheltenham Birth Centre had expressed apprehensions regarding two personnel, both of whom were midwives.
The birth centre offered midwives the option for women with low-risk pregnancies to deliver their babies there; emergency facilities were not available at the facility.
Women should have been transferred to Gloucestershire Royal Hospital, a 30-minute drive away and a subsidiary of the same Trust, in the event of complications.
However, the two midwives both failed to convey their patients promptly.
Tragic Failures in Maternal Care
Jasper White passed away in July 2019, followed by Margot Bowtell in May 2020.
The two on-duty midwives who were responsible for both deaths are presently the subject of an investigation by the Nursing and Midwifery Council, their governing body.
One is subject to suspension, while the other faces interim practice restrictions. Both midwives to whom we addressed letters received no response.
The Care Quality Commission has assigned inadequate safety ratings to 10% of maternity units in England, including the Trust in Gloucestershire.
They assert that the situation is “desperate” and have repeatedly brought to the attention of administrators a perilous staff shortage.
In May 2020, Laura Harvey and Craig, her partner, arrived at the Cheltenham Birth Centre, filled with anticipation and apprehension about the arrival of their first child.
Laura experienced two episodes of haemorrhaging during the night while in labour but claimed the midwife attending to her reassured her that there was no cause for concern.
The haemorrhaging was not communicated to the subsequent midwife on duty by the midwife.
After six hours of labour, Laura began to suspect something was amiss.
She requested an ambulance to transport her to the obstetrics unit at Gloucestershire Royal Hospital on two separate occasions. In response to her third request, paramedics arrived by lunchtime.
Laura recalls there was “some commotion in the room” then, and they could not determine the baby’s pulse rate.
She recollects the midwife staring at her, and the terror on her face engulfed me in dread.
Tragic Failures in Maternal Care
She states, “By this time, I was beginning to get a terrible feeling in my stomach, which indicated that something was absolutely, positively wrong.”
Michelle claims that Margot was lifeless and pallid at the time of her eventual birth.
Then, Infant Margot was transported to Gloucestershire Royal Hospital’s neonatal unit.
The infant was transported to Bristol, 35 miles away, for additional specialised care hours later.
The removal of Margot’s life support occurred three days later. Her parents were with their infant for ninety minutes before her passing away.
We then returned home while the back seat of the vehicle was vacant.
The Healthcare Safety Investigation Branch (HSIB) conducted an independent investigation into the cause of Margot’s demise.
It was determined that Laura ought to have been transferred to the obstetrics unit at Gloucestershire Royal Hospital due to the labour haemorrhage; had this occurred earlier, the prognosis for her child might have been different.
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Eleven months prior, the identical pair of midwives responsible for the delivery of Margot failed to dispatch an ambulance for the birth of Jasper promptly.
Within minutes of Jasper’s birth at the Cheltenham Birth Centre, his condition deteriorated significantly. But according to his mother, Laura White, the midwives appeared unconcerned.
Laura said she was not alarmed when one of the midwives exhaled him and “quite happily returned him to me.”
However, infant Jasper required immediate medical attention, which caused a fifty-minute delay in his transfer to the neonatal unit located in Gloucester.
He passed away eleven hours following his birth.
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