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Midwifery supervision and regulation: recommendations for change

Our cases

We are highlighting three cases in which local statutory supervision of midwives failed. All three cases concern events that took place at Morecambe Bay NHS Foundation Trust (the Trust) and, specifically, how those events were investigated through midwifery supervision and regulation.

The families who complained to us could not mourn the loss of their loved ones properly because of the unanswered questions they had about the care provided during the births of their children. The fact that these questions were not addressed appropriately through the processes that are in place is a theme across each of the cases, as is the failure to learn from poor midwifery care, which could have resulted in future service users being put at unnecessary risk.   

We have published the three cases in full and have laid them before Parliament. 

You can see the reports on our website:www.ombudsman.org.uk.  We have briefly summarised each case below.

Mrs M and Baby M

What happened

Mrs M went into Furness General Hospital in July 2008 for the birth of her son. Sadly, there were problems during her labour and she died after the birth, despite attempts to resuscitate her. Her son, Baby M, died the next day because he had been deprived of oxygen during the birth. 

Two of the Local Supervising Authority’s (LSA) Supervisors of Midwives, Midwife A and Midwife B, reviewed the records and decided that there were no midwifery concerns that would warrant a supervisory investigation. Mr M told us that, as a result of their decision not to investigate, he and his wife’s family had not been able to mourn the deaths of mother and baby.

What we found

Midwife A should have identified a number of failings in the midwifery care provided for Mrs M, who was a high-risk mother because she had diabetes and was having her labour induced. Baby M’s heart should have been monitored at regular intervals using continuous fetal heart monitoring from the moment Mrs M arrived in the delivery suite. The fact that this was not done should have prompted a decision to investigate.

The Strategic Health Authority (SHA) should have gone much further than they did in investigating the original decision by the Supervisor of Midwives not to undertake a supervisory investigation. As a result, they did not give Mr M an evidence-based explanation of that decision. They also said that the decision by the Supervisor of Midwives was sound when the evidence was clear that a supervisory investigation should have been carried out. 

As a result of their decision not to investigate, Mr M and his wife’s family had not been able to mourn the deaths of mother and baby.’

Baby Q

What happened

Ms Q went to Furness General Hospital in September 2008 and had her labour induced. There were complications during labour and, sadly, Baby Q was stillborn. The post mortem showed that Baby Q had not had enough oxygen during the birth. 

Seven months later, one of the LSA’s Supervisors of Midwives (Midwife B) reported on her investigation into the care provided by the two midwives at the birth. She concluded that both midwives needed more training on monitoring a baby during labour. There was then a second investigation by the Trust into 11 cases in which one of the midwives had provided care. The report of this investigation recommended that the midwife should undergo supervised practice for at least 150 hours.

Ms Q and Mr R complained to us that the LSA had failed to carry out an open and effective investigation into the death of Baby Q and that the SHA had not dealt with their complaint about this effectively. This added to the distress they felt as a result of their loss.

What we found

The supervisory investigation should have taken place in 20 days. It was seven months before it was started. The investigation was not independent and subsequent reports were not thorough. This meant that they did not identify that care fell short of relevant guidelines and good practice.

Midwife B did not identify all the failings in midwifery care given to Ms Q, and she did not establish why some actions were not carried out, for example, why the midwife had not started electronic monitoring of Baby Q’s heart when it was beating faster than normal. Midwife B also did not explore in enough detail an earlier failure by one of the midwives to start electronic fetal heart monitoring. The LSA Midwifery Officer had an opportunity to explore some of the issues that had arisen from the supervisory investigations and raised a query about whether midwives were comfortable in contacting consultants, but did not follow this up. Overall, the LSA failed to carry out its functions adequately.

When Ms Q complained to us about the SHA, they said they would investigate. They tried to be open and accountable in their review but Ms Q had to wait more than a year for their response. This meant that the reassurance she might have had from their report was diluted by the delay.

The reassurance Ms Q might have had from their report was diluted by the delay.’

Baby L  

What happened

Mrs L went to Furness General Hospital in October 2008 when her waters broke. She explained that she had been poorly for a few days, but after two sets of observations she was told she could go home and return the next day. Two days later she started to have contractions and Baby L was born. Mrs L was given antibiotics because she felt unwell, but no antibiotics were given to Baby L, who was only seen by a paediatrician 24 hours later. Baby L’s condition deteriorated and he was transferred to two different trusts for intensive treatment. Sadly, he died from pneumococcal septicaemia in another hospital early in November.

The Trust commissioned an external review of Baby L’s care but this was difficult because Baby L’s observation chart went missing around the time he was transferred to another hospital. The external report said that ‘the care received by [Baby L] was not acceptable’ and that ‘as a direct consequence, he lost his fight for life’.  

After the external inquiry, the LSA issued their report. This report did not agree with all of the findings of the external report, and Mr L felt it was fundamentally flawed. The SHA agreed to commission an external review of the report and then, following Mr L’s complaint about this first review, a second review, jointly with the Nursing and Midwifery Council (NMC). 

What we found

The LSA did not carry out its duty to perform open and effective supervisory investigations in line with relevant standards and established good practice. The supervisory investigation should have been completed in 20 days but it was delayed until after the Trust’s external investigation. This meant that events were no longer fresh in the midwives’ minds, which was particularly important without the observation chart. The report was of poor quality, and was based on assumptions. It did not establish why Baby L was put on a cot warmer on more than one occasion, why the midwives had not asked for paediatric support and whether they would do so in future.

When Mr L provided fresh information about Baby L’s temperature, which was accepted by the midwives, this meant that the original report was unsound. But the LSA Midwifery Officer did not tell the NMC about the new information and so failed to take an opportunity to put things right. 

The first review commissioned by the SHA took six months and it did not consider the actual midwifery care provided to mother and baby. As a result, these six months were wasted. The second review was open and accountable and correctly identified many of the issues. 

The LSA Midwifery Officer did not tell the NMC about the new information and so failed to take an opportunity to put things right. ’