One of the largest trusts in the country has strengthened leadership in maternity in response to the death of a baby whose parents claim a series of errors by midwives were to blame for the “completely avoidable” tragedy, it has told Nursing Times.
In a highly publicised case, Jack and Sarah Hawkins’ baby Harriet was stillborn at Nottingham City Hospital on 17 April last year, after what the couple claim was a “mismanaged labour”.
“We are introducing a strengthened leadership structure in maternity”
Despite a number of internal and external reviews, the couple say they are still seeking answers and claim there has been a “cover up”, which Nottingham University Hospitals NHS Trust has denied, though it has accepted there were “shortcomings in care”.
In a twist to the case, the couple are both employed by the trust – Mr Hawkins as a hospital consultant and Ms Hawkins as a senior physiotherapist.
In response to a series of questions from Nursing Times (see document attached below), Nottingham University Hospitals stated that, in response to the case and a wider maternity review, it had made “substantial changes” to its systems of clinical care, governance processes and personnel.
Leadership changes outlined to Nursing Times include a new director of midwifery and women’s services post in order to lead on developing maternity services with the Local Maternity Network.
“The trust has strengthened its work to involve and inform patients and their families”
Under the new structure (see flowchart below), the director of midwifery will oversee the head of midwifery, who will in turn be supported by a consultant midwife and deputy head of midwifery, quality and governance.
Joy Payne joined the trust as director of midwifery in March this year. It is currently recruiting to the head of midwifery and consultant midwife roles, while the deputy head of midwifery is also already in post.
Other new leadership roles include band 8 expertise in the labour suite to “enhance and support the midwifery team”, said a trust spokesman.
The new structure sees clinical midwifery managers introduced for the labour suites at both QMC and Nottingham City alongside lead midwives for clinical services at both sites.
Nursing Times has been told that matrons for community, gynaecology and the QMC site are in place. However, the new band 8a roles have yet to be filled and are at varying stages of the recruitment process.
“In the interim, an experienced midwife has been appointed as quality and safety lead and the service has accessed support to review the workforce requirements across the maternity pathway,” said the spokesman.
Trust strengthens midwifery leadership in wake of ‘tragic case’
One review of the case raised concerns about a lack of clarity when it came to the roles and responsibilities of band 7 midwives, especially when it came to recording professional advice and establishing the skills and experience of less experienced staff on duty to ensure they got the right support.
The trust said the band 7 role was “clearly defined with roles and responsibilities outlined in the job description”.
“The appointment of the 8a senior midwives to the labour suite lead posts will enable further work to be done to strengthen this important leadership role on the labour suite,” said the spokesman.
“Band 7 midwives are responsible for the day to day co-ordination of the labour suite and support midwives to deliver safe care to women and babies.”
In addition, following the claims around a lack of openness, the trust said it was working to ensure families were informed and involved when things did not go to plan.
“The trust has strengthened its work to involve and inform patients and their families when it comes to adverse outcomes including baby deaths and more generally when things go wrong, in line with duty of candour requirements,” said the spokesman.
“Parents’ questions are actively sought as part of the investigation process,” he said. “The trust recognises there is still work to be done in this regard but it is committed to ensuring that we hear and respond to parents in a timely and effective way.”
A detailed summary of the case, compiled by the couple’s legal team states that Ms Hawkins started experiencing contractions a day after her due date on 11 April 2016.
According to the couple’s lawyers, the pregnancy was considered low risk and suitable for midwife-led delivery. The plan was for her to give birth at the Queen’s Medical Centre (QMC) in Nottingham.
Over the next few days, the couple made 10 phonecalls to the trust and two visits where Ms Hawkins was assessed, reassured and sent home.
However, they have claimed these “touch points” were “littered with gross errors and mismanagement, which led to Harriet’s death”. These include:
- Failing to diagnose active labour
- Failing to review Ms Hawkins before she was discharged after being given “a very significant amount of opiates”
- Failing to perform a cervical examination, which lawyers say would “almost certainly” have resulted in her staying in hospital
- The fact Ms Hawkins was eventually admitted to Nottingham City Hospital because the QMC had closed its doors to new admissions due to understaffing
- Lead midwife failing to identify an obstetric emergency despite the fact Ms Hawkins’ “waters were hanging out”
- Confusing maternal pulse with foetal heartbeat
- Leaving Ms Hawkins in labour for more than nine hours despite Harriet being dead
Harriet was pronounced dead after 37 weeks of pregnancy – when the majority of babies “should be expected to be born alive”, noted the document from Switalskis Solicitors (see attached PDF below).
It goes on to describe how the couple were initially told by the trust she had died as the result of an “infection”, but they were not convinced and pushed for an external review.
A serious untoward incident (SUI) investigation was carried out but this was later deemed “unfit” by the local clinical commissioning group. A second SUI is currently underway and due to report shortly.
“We fully recognise there were shortcomings”
Meanwhile, an investigation by the Midlands and East Local Supervising Authority (LSA) raised a number of concerns about the way that midwives handled Ms Hawkins’ labour and Harriet’s birth.
The report shows that, of 13 midwives who were involved in the case, 11 were told they must undertake extra learning or training exercises.
Two were required to undertake extensive LSA Practice Programmes to address concerns. These included a “failure to adequately record care in detail” and “lack of professional accountability”.
One member of staff was also criticised in the report for her “failure to support inexperienced midwives in complex situations within labour ward environments”.
The trust confirmed to Nursing Times that all 11 midwives in question were still employed by the trust and “the programme of remedial work has commenced”.
“None of the findings from the LSA report were significant enough to warrant an NMC referral,” said a trust spokesman.
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In a statement, trust chief executive Peter Homa said: “I reiterate my condolences to Jack and Sarah and acknowledge the unimaginable distress and sadness caused by Harriet’s death.
“I apologise unreservedly that their pain has been worsened knowing that had the shortcomings in care late in Sarah’s pregnancy not been experienced, Harriet might be alive today,” he said.
Mr Homa said the trust “fully recognise there were shortcomings” and that it had “completed a full review of patient safety and outcomes in its maternity service since this tragic case”.
But he added: “While areas of improvement have been identified, there is no compelling evidence to suggest that outcomes in our maternity services are different to those in other similar maternity units in England and Wales.
“We have learnt from all of these incidents and are committed to doing everything we can to provide the safest and best quality care for our mothers and babies,” he said.