GLOUCESTERSHIRE Hospitals Foundation NHS Trust has accepted liability for the death of new-born baby.
The mother of a baby who died three days after her delivery has spoken of her devastation at losing her child to a hypoxic brain injury following failings at a midwife-run NHS birth centre in Cheltenham.
The Trust has accepted liability for the death of Margot Frances Bowtell, who was born on May, 14 2020, after admitting the presence of blood-stained liquor noted during labour should have led to a referral to the obstetric team and that failure to do so was a breach of duty.
Had Margot undergone obstetric review it was noted, her delivery would have been expedited and she would still be here today.
Laura Harvey, 34, Margot’s mother, who lives in Gloucestershire, wants to raise awareness to help ensure similar midwifery failures do not cause other families the same grief.
Laura had an episode of vaginal bleeding at 34 weeks which should have resulted in her care being discussed with a Consultant Obstetrician and Laura should have been given the choice of giving birth at Hospital. A midwifery-led pathway was chosen for Laura without any risk assessment or discussion of problems that might arise during the remainder of her pregnancy or labour.
Just after midnight on May, 14, Laura was admitted in labour. Two hours later, she was examined and found to be 3cm dilated with her waters intact.
Her waters broke at 3.50am hours later with blood-stained liquor also noted, she then had a second instance of blood-stained show a few hours later just after 6am.
Subsequently, during a shift change at approximately 07:30, there was no documented handover of Laura’s care and the midwife who took over was not informed of the presence of blood-stained liquor during the night.
By 11.15, Laura was said to be fully dilated, national guidelines says a mother should then be monitored every five minutes, but this didn’t begin for almost an hour.
Laura requested a transfer to an obstetric-led unit elsewhere three times, starting at 11:00. An ambulance was finally called at 13.00, but staff felt that delivery would happen prior to transfer as the baby’s head was advancing well.
Margot’s heart rate, however, had been erratic and was exceptionally low at 13.25, when another midwife was called in to assist. following an episiotomy, she was delivered at 13.31 but in poor condition, making no respiratory effort.
She was rushed for CPR and transferred to the obstetric-led unit, with fluids and antibiotics administered intravenously. She was then transferred to Bristol Neonatal Intensive Care Unit, where she remained intubated and ventilated for three days.
An MRI scan of her head at two days of age showed an “acute near total hypoxic ischaemic insult” from which she would not be able to recover.
Her family made the heart-breaking decision to withdraw life support and Margot died on May, 17.
Sarah Stocker of Tees Law, who acted for the family said: “The midwives failed to follow the Hospital Trust’s own guidelines that mandated that an obstetrician be consulted and CTG monitoring commenced.
Had the midwives acted appropriately at 03:50, 06:10 or 07:30, Laura would have been transferred for obstetric-led care. There would have been continuous CTG monitoring of Margot, and she would have been delivered at the first sign of fetal distress,”
Laura Harvey, Margot’s Mum said: “The personal guilt I carry will always stay with me, even knowing now it was nothing I did wrong. Knowledge is power and I feel midwives hold the key to informing expectant parents of the good and bad things that come with any pregnancy, whether it is your first or fifth time.
“Saying goodbye to our beautiful baby girl is the hardest thing I have ever had to do and knowing it could have been prevented is even harder to live with.
“All I can do now is help raise awareness of baby loss and to make sure the Gloucestershire Trust implement all the safety recommendations that our investigation unearthed and help prevent the devastating loss of another baby the way in which it happened to Margot.”
Sarah Stocker, added: “Gloucestershire Hospitals NHS Foundation Trust could have averted this tragic outcome if warning signs during pregnancy and labour had been recognised and properly acted upon. The devastated family are relieved, at least, that the Trust has now finally admitted liability.