Two midwives have been struck off after they delayed the assessment of a pregnant woman, leading to the death of her infant.
The pregnant woman, suffering from vaginal bleeding at the time, was made to wait almost 40 minutes to be assessed when she arrived at King’s Mill Hospital in Sutton-in-Ashfield.
The hospital also failed to respond to requests for help from the patient’s family, a Nursing and Midwifery Council (NMC) panel found.
The woman, who has remained anonymous, was 41 weeks pregnant when she arrived at the maternity unit with vaginal bleeding in the early hours of September 13, 2023.
She had been at the hospital earlier suspecting she was in labour, but was sent home.
Shortly after midnight, she called with concerns around bleeding and was told to return the facility.
The telephone triage midwife did not update the system, but had verbally told Glenys Wood and Kathryn Duignan that the patient was bleeding and would be arriving at the unit.
There were no other patients in triage and none were expected.
Despite this, the woman was left waiting to be assessed for 37 minutes.
On the night in question, Ms Duignan was in charge of the triage team as the only Band 7 maternity ward co-ordinator on duty, though the NMC report highlights that the maternity department “was understaffed generally” and that there should have been two.
Despite Ms Duignan being near the front desk when the patient – who was “plainly in pain” – arrived in a wheelchair, the midwife did not triage her because she expected another colleague to, the panel found.
The NMC did not accept this, as this colleague was a birthing midwife in an understaffed unit, not a triage midwife.
When the colleague in question later came to the ward and asked if the patient had been assessed, she triaged her herself at 1.42am.
The NMC report said “it was immediately apparent to her that there was a medical emergency”, but in the meantime Mrs Wood had gone on a break.
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The panel heard that Ms Duignan wrote a sign saying “gone for a break, back in 30” and placed it on Mrs Wood, who was sitting at the triage desk in public view.
The baby died of a brain injury because of a lack of oxygen and blood flow to the brain, which was caused by placental abruption, with an inquest in July 2024 finding neglect had contributed to his death.
The coroner ruled that if the mother had been seen on arrival, she would have had a Caesarean by at least 1.25am, rather than at 2.02am.
If this had happened, the baby “would on balance have survived”, according to the coroner.
The panel also found that both Mrs Wood and Ms Duignan failed to respond to requests for help from the family, and determined that both would have heard the patient and her family shouting based on the proximity of the room they were in to the midwives’ station.
The NMC said the actions of the midwives “were a breach of the fundamental tenet of the profession”, and neither member of staff engaged with the proceedings.
The NMC warned there was a “high risk” of this conduct being repeated in light of this.
Both were struck off the register, meaning they can no longer work as midwives.
Philip Bolton, Executive Chief Nurse at Sherwood Forest Hospitals, said: “We are deeply sorry for the care the baby and their family received. We recognise the profound and lasting impact this has had on them and know this remains an incredibly difficult time.
“The care provided that night fell far short of the standards the baby and their family had every right to expect from us.
“Following the baby’s death, we carried out a comprehensive HR process and the individuals no longer work at the Trust.
“We acknowledge the outcome of the NMC hearing and are continuing to work with the baby’s family to do all we can to prevent this from happening again.”
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