A baby died after a Wirral midwife failed to recognise a life threatening condition and did not inform colleagues of issues surrounding a high-risk patient.
Peter Clinton failed to recognise and did not report concerns around loss of contact with a baby’s heartbeat to Wirral University Teaching Hospital colleagues when dealing with a high-risk mother in December 2019. As a result of this, a condition that led to the baby’s death seven days later was not prevented.
A Nursing and Midwifery Council report said the former midwife’s actions fell “significantly short of the standards expected of a registered nurse” but he would still be able to work in a registered hospital. The document said on December 20, Mr Clinton was the only midwife working in triage with a mother - known as patient A - asked to attend at 8.30am under the assumption she may be in labour.
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Mr Clinton assessed patient A, who was 37 weeks pregnant and booked in for an elective caesarean three days later, and began electronic monitoring of Baby A’s heart rate 12 minutes later for 40 minutes. It was determined patient A was not yet in labour, but her pregnancy was high risk as a result of her previous obstetric history.
The midwife informed a colleague, referred to by the NMC as Witness 1, that patient A’s contractions were getting stronger and she was vomiting. Mr Clinton did not inform his colleague of any concerns with mother or baby at the time.
The report said he had noted episodes of loss of contact with the foetal heart monitoring that he had attributed to Patient A allegedly vomiting. After transferring patient A to the labour ward, he failed again to inform another colleague witness 3 of any issues with the mother or baby.
The electronic monitoring of the baby’s heart rate did not record anything upon transfer and Mr Clinton made “a number of attempts” to obtain a reading for around 15-20 minutes, a hearing was told last month. The report said there was “difficulty in recording Baby A’s heartbeat.”
At 9.45am witness 3 came into the delivery room and attempted to record baby’s heart rate and experienced difficulty in doing so. The report said: “She recognised that Baby A’s heart rate was very low (bradycardia), and pulled the emergency cord for immediate assistance.
Members of maternity staff came to the room. A decision was made for an emergency caesarean section, and Patient A was transferred to the operating theatre. A uterine rupture (tear) was diagnosed on incision and Baby A was born at 10:25 am, in a very poorly condition. Sadly, Baby A passed away on 27 December 2019.”
A coroner’s report found that Baby A passed away from “natural causes contributed to by the delay in recognising and diagnosing bradycardia.” Witness 1 said at no time did Mr Clinton escalate any maternal or foetal concerns and failed to ask for a review.
The witness added how at 8.50am that day, she spoke to the midwife who said all observations and the electrical heartbeat recordings were normal. Evidence from witness 3 and the baby’s father said Mr Clinton “did not appear to be acting with any urgency” when he entered the ward.
The midwife was said to have been reassured by “the fact he could hear” the baby moving, rather than establishing a heartbeat. The NMC panel presiding over the case said if this was the case, Mr Clinton should have attempted to listen to the baby’s heartbeat with a handheld device as soon as possible.
The report said: “In not doing so, he missed the opportunity of diagnosing foetal bradycardia earlier and of escalating to expedite delivery.” As a result, Mr Clinton was found to have failed to identify and or recognise when baby A was suffering a foetal bradycardia; failed to adequately escalate concerns regarding patient A’s condition and failed to adequately document the care provided to patient A.
The panel said “the immediate and timely” opportunity to report and adequately escalate patient A’s changing condition was when Mr Clinton was struggling to find the foetal heat rate on the labour ward for an extended time. It added how he failed to adequately escalate concerns despite not finding a heart rate for more than three minutes.
At minimum, the document said, the duty of adequate escalation would have been met if Mr Clinton alerted during or before his handover that he was struggling to find the foetal heart rather than making an assumption on the basis of baby A’s movement. In a reflective statement read to the panel, Mr Clinton apologised for his failures.
It said: “The effect of this incident on the family concerned is obviously catastrophic and I can't begin to imagine what they have been through in the past three years and also the effect that it will have on them for the rest of their lives. There is also a wider effect to consider, the impact of an incident like this on extended family and friends who may well lose faith in the trust concerned.
“There is also the damage that an incident such as this can have on the reputation of the midwifery profession, public trust in the profession to deliver high standards of care may be lost. I constantly reflect on this case and how things could have been different for this family and I hope they are able to move on with their lives.
“I have a deep sense of regret for the events of that day and the eventual outcome, it's an outcome that potentially could have been avoided and I can only offer my sympathy to the family concerned.” Despite Mr Clinton’s contrition, the report said both parents impacted by the incident had their confidence in the healthcare profession undermined as a result of his care.
The three-person panel said Mr Clinton’s conduct “breached the fundamental tenets of the midwifery profession and therefore brought its reputation into disrepute. They found his fitness to practise was impaired.
He is free to continue as a midwife - though is not currently employed as one - but must abide by a conditions of practice order which limits the number of providers he can work for and must inform all employers of his status.
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