Failures at Northampton hospital led to baby boy being born with brain damage
Slip-ups by a senior Northampton midwife played a role in a series of failings that led to a baby boy being born with brain injuries at NGH.
The sad circumstances surrounding the birth in 2017 saw staff at NGH fumble with the mother's care and wheel her in and out of theatre before someone made the decision she needed an emergency cesarean.
The delays in delivering the baby boy played a major role in damage the child suffered prior to birth.
Now, two years after the incident, the now-retired senior midwife on duty, Elaine Hawtin, was brought before the Nursing and Midwifery Council's disciplinary board in November to examine how she could have acted to ensure the baby was delivered sooner and reduce the risk of harm.
The incident was detailed in a report by the NMC, and show how, in mid-2017, Midwife Hawtin was on duty as the senior midwife and labour ward coordinator.
The panel heard how scans showed the unborn baby boy in the case had a worryingly-low heart rate. An emergency alarm was activated and the mother rushed to theatre.
However, it was here that a hospital registrar made a decision to send the mother back to her old ward after observing the baby had a normal heart rate for just 10 minutes. Official guidelines say that at least 20 minutes should be observed before making such a decision.
And, when two junior midwives felt unable to challenge the registrar's decision - because the registrar was 'busy' with three other mothers - Midwife Hawtin accepted the call and helped wheel her back to the ward without properly questioning why it was happening.
A serious incident investigation board later ruled that had the baby's heart rate been observed for 20 minutes, it would have been "likely" he would have been born earlier and in better health.
Within half an hour, further fears over the baby's heart rate were recorded, and the mother was again taken to surgery.
A forceps delivery was attempted but it was unsuccessful. Finally, the decision was made to conduct an emergency cesarean.
The report reads: "Baby A was born at 17:57 in poor condition. He was subsequently diagnosed with hypoxic ischaemic encephalopathy leading to a brain injury.
"[The mother and father] have described the devastation and grief that they have endured – and continue to endure – as a consequence of the significant injuries suffered by Baby A during his birth.
"They have made clear how much they cherished the prospect of becoming parents and how their experience of being parents to Baby A has led them to grieve for the child he could have been and have grave fears about his future, in particular at such time that they may no longer be able to provide care for him."
She later agreed in front of the Nursing and Midwifery Council that she should did not adequately manage or support her staff during the incident in 2017, and should have investigated why the mother was being sent back to her ward after only 10 minutes.
The panel ruled: "Midwife Hawtin failed to show professional curiosity and query or probe any of the decisions made by other midwives and the Registrar who were caring for [the mother].
"As a consequence of this she did not pick up on errors they had made. If those errors had been identified it is likely that Baby A’s outcome would have been better."
The panel noted that, had Midwife Hawtin not resigned, they would have been unlikely to strike her from the register as a punishment and would have been met with a suspension order - but nevertheless accepted her decision to retire.
Editor's note: An earlier version of this story claimed Midwife Hawtin retired in the week following the incident. This was because of a misunderstanding in the NMC's report. Midwife Hawtin retired in April 2019 for reasons unrelated to the incident and voluntarily removed herself from the register.