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Bolton NHS Foundation Trust orders maternity care review

Investigation launched into births at midwifery unit

Posted on 11 December 2015

A Serious Incident Report (SIR) following the death of a baby at the Royal Bolton Hospital has prompted an investigation by Bolton NHS Foundation Trust into all births at the trust’s birthing centre between April and September 2015.

The birthing suite is led by midwives and the review will establish whether midwives observed trust policies and referred mothers and babies to consultant-led care where necessary.

The internal SIR report identified a problem with the monitoring of the baby girl’s heart rate and found that the midwife involved in the birth departed from ‘accepted and known procedures’.

The report found that there had been a number of incidents of high and slow foetal heart rate, but the midwife did not increase the frequency of foetal heart rate monitoring, or seek a second opinion about whether the mother should be transferred to the care of a consultant.

The SIR also noted that the trust’s policy for monitoring foetal heart rate should have been updated before March 2015.

The report was shared with the family of the baby girl under regulations that came into force in November 2014 that imposed a duty of candour on NHS bodies to be open and transparent with patients about the care and treatment they provide.

Medical negligence solicitor Nicola Wainwright who has acted for many families whose babies have died during or shortly after being born said:

“Every family who suffers the loss of a baby will recognise the devastation felt by the family whose baby girl died at Bolton Hospital.

I am glad to see that the hospital did carry out a SIR which identified failings in care and which was disclosed to the family. So often that does not happen when it should.

“It is clear that in order to protect patients maternity units, whether or not they are led by midwives, must ensure that their policies and guidelines are up to date and are followed by all members of the unit and that all members of staff are trained to recognise and act on any signs of concern, such as an abnormal foetal heart rate.

“The safety of mothers and babies during labour is something that should be the top priority throughout their time in hospital or in birthing centres - what else can be more important?"