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Helping parents to get to the truth about stillbirth

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Delayed emergency caesarean section resulted in stillborn baby

On 5 November 2013, Rebecca Ponchard was 41 weeks pregnant with baby daughter Ruby when she was admitted to King’s College Hospital, London. Tragically, following a delayed emergency caesarean section baby Ruby was stillborn.

Rebecca and her husband Edward had strongly suspected that the management of Ruby’s birth had been inadequate and they sought answers from the Trust. After some months, the Trust carried out an investigation into baby Ruby’s stillbirth.

Mother and baby were failed by the midwife

The investigation concluded there had been a failure on the part of the midwife to recognise that Rebecca was a ‘high risk labour’ due to her previous medical history. The internal investigation also revealed that National Institute for Health and Care Excellence (NICE) guidelines had not been followed and that cardiotocography (CTG) equipment to monitor the fetal heart had been misused and the results misinterpreted.

However, although the investigation went some way to describing what happened, Rebecca and Edward believed it did not go far enough in explaining why and how these failures were allowed to happen.

The only recourse for Rebecca and Edward (and other parents who find themselves in this situation) is to bring a civil claim against the Trust to establish whether or not negligent care played any part in the death of their child. They instructed Sarah Harper a senior associate at Access Legal Solicitors, who specialises in stillbirth claims, to investigate a civil claim.

Lack of up-to date experience resulted in tragic errors

Rebecca and Edward made a second complaint to the Trust and raised some more detailed questions in response to which the Trust confirmed that the midwife responsible for Rebecca’s care that day had not practiced for nine months and this was her first shift back. They also confirmed that the midwife was unfamiliar with the location of vital equipment and the procedures in the maternity ward.

At present midwives have to 'revalidate” with the Nursing and Midwifery council every three years. However, in order to qualify for that revalidation and be considered competent, they are required to work only a minimum of 450 practice hours over a three-year period. Sarah Harper, explains:

‘A midwife could conceivably do approximately 60 days of work at the start of any given three year period, take two-and-a-half years off, revalidate and still be considered competent enough to supervise a child birth at the end of those three years.’

Rebecca was deeply concerned that it was her midwife’s lack of up-to-date experience and current working knowledge which had caused the errors leading to Ruby being stillborn. Ideally the couple would like to see the registration and revalidation process regulated more strictly so that any gaps in a midwife’s training and experience are identified and addressed before they are able to practice unsupervised.

The inadequacy of the investigative process in stillbirth

In 2013 the NMC introduced a process called ‘voluntary removal’ which allows a midwife who is subject to a fitness to practice allegation to apply to be removed permanently from the register without a full public hearing - if they admit that their fitness to practice is impaired and do not intend to continue practicing.

The midwife involved removed herself from the NMC’s register of Midwives, so the NMC had no jurisdiction to investigate her failings.

This decision by the midwife frustrated Rebecca and Edward’s search for answers.

However, as Sarah points out, the NMC states that voluntary removal will not be allowed where the allegations are so serious that public confidence in professional standards would suffer if they were not dealt with at a public hearing.

Rebecca and Edward believe that their case is exactly such a circumstance and that it is unfair to deny them a full investigation and deny the NMC an opportunity to learn lessons.

Hope for improvement in investigation of stillbirth

At the moment, if a baby dies after 24 weeks of pregnancy, before or during labour, the death is classified as a stillbirth. These cases are not currently subject to an inquest. Encouraging news came with health secretary Jeremy Hunt’s announcement in November last year that all cases where babies die unexpectedly during childbirth will be independently investigated.

This step is welcomed because it means all stillbirths will now be independently investigated as a matter of course and this will reduce the pressure and onus on the family to have to take their own steps to try and find out what happened and why it happened.

At the conclusion of the legal case, King’s College Hospital issued a letter of apology to Rebecca and Edward, acknowledging that lessons needed to be learned following their investigations. The couple still feel however that there are many questions unanswered and had a coroner’s inquest or investigation been held, they would have been spared years of anguish and trauma.

couple where lady is pregnant

Pictured above: Edward and Rebecca in happier times.

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