Patient safety during maternity care called into question

Tees’ Clinical Negligence team advocates for campaigning for patient safety concerning antenatal, maternity, and neonatal care.

A BBC Panorama documentary which aired on Monday 29 January 2024, looked at maternity care at Gloucestershire Hospitals NHS Foundation Trust, including the Cheltenham Birth Centre. 

Tees’ client Laura Harvey, from Gloucester who lost her baby Margot Frances Bowtell at just three days old, recalls her dealings with Gloucestershire Hospitals NHS Foundation Trust in 2020 after the hospital admitted liability for failures in her care which caused Margot’s death.

Baby Margot was born on 14 May 2020 at the midwife-run Cheltenham Birth Centre and passed away on 17 May 2020 at three days old, because of a hypoxic brain injury sustained during her delivery. 

Laura and Margot’s care was provided by two midwives who are no longer working at the Trust and are both the subject of an ongoing NMC investigation into the circumstances surrounding Margot’s death. 

A report by the Healthcare Safety Investigation Branch (HSIB) later identified multiple issues with her care, including a failure to update mother Laura’s risk assessment after she experienced an episode of reduced fetal movements and a bleed at 34 weeks pregnant. This meant Laura was admitted to a low-risk ward led by midwives when she went into labour at 41 weeks, but she should have been given the opportunity to give birth on the consultant-led unit.

Whilst in labour, Laura experienced episodes of bleeding, but this was not escalated to the obstetricians on call, nor was this information handed over between the midwives during the shift change on the morning of 14 May 2020. HSIB found that the episodes of bleeding meant that a referral to the obstetric led unit was necessary for continuous monitoring of Laura and Margot.

Gloucestershire Hospitals NHS Foundation Trust admitted liability for failures in Laura’s care which caused Margot’s death.

Associate Sarah Stocker said: “The midwives involved did not follow both national guidance and the hospital’s own clinical guidance on several occasions during Laura’s labour. If the midwives had acted in the hours before Laura gave birth, when they had many opportunities to do so, Laura would have been transferred to the appropriate ward for obstetric led care. There would have been continued monitoring of both mother and baby, Margot would have been delivered at the first sign of fetal distress and she would still be with us today.”

Laura Harvey said of the two midwives and the ongoing investigations: “As a family, we want and more importantly deserve to know why both midwives made the decisions they did and why they chose to directly ignore and not follow the Trusts own standard practice procedure. It was not just one point where they failed to escalate my care, it was a series of failures.” 

Laura happily went on to safely deliver a baby daughter at Gloucester Hospital in December 2023. She was cared for by the Rainbow Team and this time had an incredibly positive experience. 

Laura Harvey, said of safety in maternity care: “There are midwives who are working hard and following the safety procedures in place to bring babies into our world and who are going above and beyond to help everyone. 

It should not be a postcode lottery where you give birth and the care that you receive. Midwives and Doctors need to follow the national set of safety procedures. 

We need to be highlighting the Trusts who are exceeding and sharing knowledge with the Trusts who are currently struggling, and most importantly, we need to be sharing and learning from what happened to Margot to prevent it ever happening again.”