Sponsored by
Baby death: midwife cautioned
A MIDWIFE who resigned to "make amends" after a mother lost her baby during a traumatic childbirth was yesterday given a caution order for 12 months.
Judith Best, 58, of Scarborough, failed to act after student midwife Davina Eames reported the heavy blood loss at Bridlington Hospital, the Nursing and Midwifery Council was told.
The infant, whose mother was referred to at the hearing as Mrs A, was transferred to Scarborough Hospital's A&E department on January 27 2005 and delivered swiftly but there was no heartbeat. All attempts to revive the baby proved fruitless and it was stillborn.
Best, who had a flawless 27-year record in midwifery, admitted she should have paid more attention to Ms Eames than she did when she took over her supervision at 5.40pm. The midwife also admitted to the panel that she did not review the patient's notes as thoroughly as she could have done.
And vital equipment needed for listening to the baby's heartbeat was missing from an emergency travel bag during the transfer between hospitals.
Panel chairman Elizabeth Rush told the hearing that Best should not shoulder the blame for not checking the baby's heart rate in the ambulance.
But the hearing was told that if Best had checked Ms Eames' notes the baby would have stood a better chance of survival.
Ms Rush told Best: "The panel accepts that in the particular circumstances of this case you could not be criticised for failing to monitor the foetal heartbeat in the ambulance travelling between Bridlington and Scarborough.
"Your essential failing is that you failed properly to supervise the student midwife who was attending Mrs A, and to ensure that proper records were kept.
"When you took over the care of Mrs A and supervision of the student midwife at about 5.45pm you should have immediately read the notes made by the student midwife in the labour record.
"If you had read the notes you would have been alerted to and been concerned about her level of competence, and you should then have supervised more closely.
"You would have had the opportunity to cause more frequent observations to be made and to take action earlier than you did.
"Whether the outcome would have been different, it cannot be known. But you did have a duty to ensure that Mrs A had safe and competent care."
Ms Rush also told the hearing Best's actions only warranted a caution because she admitted her mistakes and has since retired from midwifery.
She added: "The panel accepts that although there was a serious departure from the NMC code of conduct, there was a prompt and full admission of responsibility.
"You have never attempted to deny that your conduct fell below acceptable standards in the supervision of a student midwife and ensuring proper record keeping. You have not practised as a nurse or as a midwife since then, and have decided to allow your dual registration as both nurse and midwife to lapse.
“You have taken up employment in another caring capacity, and have indicated that you do not intend to practise again as a nurse or midwife.”
Giving evidence, Best told the panel how a stethoscope and a sonic aid used to listen to the baby’s heart rate had gone missing from the transfer bag.
But she claimed that even if she did have the sonic aid, she did not have the equipment in the ambulance to have helped the baby if it was born with a low heart rate.
Best wept as she told the hearing she decided to resign because she wanted to make “amends” to the baby’s parents.
She said: “I was absolutely devastated by the events of that night. I knew I had made mistakes.
“On that one occasion I had made mistakes and that’s why I decided to resign, because I could not let it happen ever again.”
The hearing was told Best had an “extremely demanding role” at a time when there was a “shortfall” of midwives compared with the previous year.
Best, who has since retired, admitted failing to adequately supervise Ms Eames during the delivery, failing to ensure that the foetal heart beat was auscultated (listened to) at five-minute intervals and failing to adequately monitor the mother’s blood pressure.
She also admitted failing to monitor the foetal heartbeat when Mrs A was taken to Scarborough hospital in the ambulance and failing to make adequate records in relation to Mrs AM’s labour.
But the panel threw out the charge that she failed to establish the onset of labour, and ruled that the allegation of failing to take appropriate action when Ms Eames reported blood loss as not proved.
Email to a friend
Print this page
Looking for...
Featured advertisers
Jobs
Search for a job
Motors
Search for a car
Property
Search for a house
Weather for Scarborough
Friday 25 May 2012
Today
Sunny
Temperature: 11 C to 18 C
Wind Speed: 24 mph
Wind direction: East
Tomorrow
Sunny
Temperature: 10 C to 17 C
Wind Speed: 21 mph
Wind direction: East
