Midwives Face Career End After Misconduct in Infant Deaths

The careers of two midwives are in jeopardy after they did not secure emergency medical attention for two infants who were unwell, leading to the babies “losing a significant chance of survival”. Jasper White passed away in June 2019, and Margot Bowtell died in May 2020; both had been born at the Cheltenham Birth Centre. Hazel Williams and Lisa Land, who were the midwives on duty during both deliveries, were found by an investigation to have neglected to ensure the prompt transfer of both infants to neonatal intensive care. On Tuesday, the Nursing and Midwifery Council (NMC) panel determined that the midwives had engaged in misconduct and that their capacity to practice was compromised. Additionally, the panel established that both midwives subsequently falsified Jasper’s medical records. Neither of the midwives attended the hearing nor were they represented. The birth centre, which operates under the Gloucestershire Hospitals NHS Foundation Trust, provided a setting for women with low-risk pregnancies to deliver their babies outside of a bustling hospital environment. However, the facility lacked emergency services, necessitating the transfer of patients experiencing complications to the Gloucestershire Royal Hospital, located a 30-minute drive away. Jasper’s condition worsened rapidly after his birth, yet a 50-minute delay occurred before his transfer to the neonatal unit in Gloucester, and he passed away merely 11 hours post-delivery. The NMC panel determined that Ms. Williams, who was the senior midwife, neglected her responsibility to escalate Jasper’s situation to facilitate his transfer to a neonatal team. It was also established that she had urged Ms. Land to alter medical notes, changing the description of his condition from “poor” to “good” three days following his death, and that she had inserted additional entries into his records. The three panel members concluded that Ms. Land similarly failed to escalate Jasper’s condition to the neonatal team and that her intention was to deceive anyone reviewing the medical notes. Eleven months subsequent to this, in May 2020, Laura Bowtell experienced two bleeding episodes during her labor, yet her repeated requests for transfer to a hospital were not fulfilled. Her daughter, Margot, was not breathing at birth and, despite being urgently transported to a hospital, died three days afterward. The NMC panel determined that Ms. Williams neglected to transfer Ms. Bowtell to obstetric care despite Ms. Bowtell’s requests, and that she also failed to inform the receiving hospital about Margot’s decreasing heart rate during the baby’s transfer. The panel also found that Ms. Williams subjected patients to potential harm or neglect by cultivating an inadequate culture within the unit, where lessons derived from serious incidents were not shared with staff members. The panel concluded that Ms. Land was cognizant that Ms. Bowtell was not an appropriate candidate for midwifery-led care but did not arrange for her transfer to a hospital. It was further established that she had documented the presence of blood staining in the amniotic fluid and a low maternal temperature, but subsequently made dishonest claims that these records were incorrect. Ms. Land subsequently sent WhatsApp messages to Ms. Bowtell without clinical justification, an action the panel deemed a violation of professional boundaries. Derek McFaull, the panel chair, stated that Ms. Williams and Ms. Land had not adhered to the standards of their profession, had not treated their patients as individuals, and had neglected their responsibilities regarding honesty. He further noted that their conduct contributed to Jasper and Margot “losing a significance chance of survival”. Mr. McFaull indicated that they had tried to conceal their actions through “inaccurate or dishonest record keeping” and that there was an “increased risk of harm to patients due to staff not being up-to-date”. Mr. McFaull observed that neither Ms. Williams nor Ms. Land demonstrated “insight or remorse” or any comprehension of the consequences of their actions on the patients and their families. He expressed concern that both individuals might be prone to repeating their actions in the future. The panel is scheduled to decide the disciplinary measures the two midwives will face on Wednesday. Readers can follow BBC Gloucestershire on Facebook, X, and Instagram. Story ideas may be submitted via email or WhatsApp at 0800 313 4630. Copyright 2024 BBC. All rights reserved. The BBC bears no responsibility for the content of external websites. Further details on our approach to external linking are available.