Midwives responsible for string of failures in hours before baby's death, regulator finds
A midwife at Shropshire’s hospital trust deliberately mis-reported patient call notes in a bid to cover up failures leading to the death of a baby just hours after she was born, a Nursing and Midwifery Council (NMC) panel has found.
The fitness to practice hearing upheld a string of charges detailing how Claire Roberts, along with fellow midwife Joanna Young, did not respond as they should when concerns were raised by the parents of Pippa Griffiths, who died in April 2016 at just a day old.
They faced 14 charges of misconduct between them, with 10 found proved in full, two proved in part and two found not proved.
“It’s been a difficult process,” Pippa’s mother Kayleigh, who had to give evidence as part of the hearing, said.
“There doesn’t seem to have been any part of it which has been made any easier.”
She and Pippa’s father Colin were the ones who reported the pair to the NMC, after Shrewsbury & Telford Hospital Trust failed to do so.
“I think for me that’s one of the things that stands out because the Trust wouldn’t have reported them to the NMC,” she added.
“And obviously it’s serious enough that the majority of the charges have been proven. And if we hadn’t carried on pushing for it they would still be free to be practising.”
Within hours of Pippa’s birth, her parents say they noticed warning signs that she was unwell - including difficulty feeding, and bringing up brown mucus.
When they raised concerns with midwives, they say, they were dismissed.
But Pippa was dangerously ill. She had contracted group B strep, which became meningitis. She spent little more than a day with her parents, and older sister Brooke, before she stopped breathing.
The NMC panel found that the evidence proved Claire Roberts, in a call at 2.30am the day Pippa died, did not conduct a comprehensive assessment of Pippa’s condition - including failing to ask about her breathing and temperature.
They also found that she made an “inaccurate” record of the call, including that Kayleigh “had no other concerns” other than “reassurance with regards to breastfeeding”.
“Your conduct… was dishonest in that you knowingly intended to create a misleading impression of [Kayleigh’s] concerns regarding [Pippa] during the telephone call,” the final charge states.
Against Joanna Young, the panel found it had been proved that she also failed to carry out a full assessment in a call later that morning, at 9am, including failing to ask about Pippa’s alertness, breathing, temperature and colour.
She also failed to follow instructions from a senior midwife to visit the family.
Both midwives, neither of whom still work for the Trust, will face a further hearing in March to determine whether the failures amount to misconduct, and whether that means they are not fit to practice.
“It’s still bittersweet no matter what the outcome is really,” Colin said.
“We’re facing our fifth Christmas without Pippa now and it doesn’t get any easier,” Kayleigh added.
“I think it’s really important that midwives look at the case and look at your practice, and think about when a mother does call up in the middle of the night at 3 o’clock in the morning with concerns, listen to that mother and just get her to come in.
“Just get her seen because it’s better to be safe than having a baby missing at Christmas.”
Pippa’s death was one of the two which first sparked the ongoing independent review of maternity care at Shrewsbury & Telford Hospital Trust.
Together with the family of Kate Stanton-Davies, a newborn who died in 2009, Kayleigh and Colin campaigned for an inquiry into 23 cases of poor care.
That quickly spiralled and now, the review - led by midwife Donna Ockenden - covers 1,862 cases, while a police investigation is also underway.
Hayley Flavell, director of nursing at the Trust, said: “We note the judgement made by the Nursing and Midwifery Council and again offer our sincere condolences to the family over the loss of their daughter.
“We recognise our previous failures in the standard of care offered to mothers and babies, for which we have apologised unreservedly, and we are committed to taking all of the steps necessary to improve the safety and quality of care that we provide to the women and families that we serve.”
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