Midwives struck off after bleeding pregnant woman left waiting nearly 40 minutes and lost her baby

Two midwives have been struck off after they left a bleeding pregnant woman waiting for nearly 40 minutes to be assessed after she arrived at hospital, leading to the death of her baby.

The staff at King’s Mill Hospital in Sutton-in-Ashfield also failed to respond to requests for help from the patient’s family, a Nursing and Midwifery Council (NMC) panel found.

The woman, who has remained anonymous, was 41 weeks pregnant when she arrived at the maternity unit with vaginal bleeding in the early hours of 13 September, 2023.

She had been at the hospital earlier suspecting she was in labour, but was sent home. She called again a little after midnight with concerns about bleeding and was told to come back in.

The telephone triage midwife did not update the system, but had verbally told Glenys Wood and Kathryn Duignan that the patient was bleeding and would be arriving at the unit.

There were no other patients in triage and none were expected.

Despite this, the woman was left waiting to be assessed for 37 minutes.

On the night in question, Miss Duignan was in charge of the triage team, though the NMC report highlights that the maternity department “was understaffed generally”.

She was the only Band 7 maternity ward co-ordinator on duty when there should have been two.

The NMC panel found that Miss Duignan was in the vicinity of the front desk when the patient arrived in a wheelchair and “plainly in pain”.

The woman was put in a side room by Mrs Wood, who did not triage her as she said she was expecting another colleague to.

The NMC did not accept this, as this colleague was a birthing midwife in an understaffed unit, not a triage midwife.

When the colleague in question later came to the ward and asked if the patient had been assessed, she triaged her herself at 01.42am.

The NMC report said “it was immediately apparent to her that there was a medical emergency”.

In the meantime, Mrs Wood had gone on a break.

The panel heard that Miss Duignan wrote a sign saying “gone for a break, back in 30” and placed it on Mrs Wood, who was sitting at the triage desk in public view.

The baby died of a brain injury because of a lack of oxygen and blood flow to the brain, which was caused by placental abruption.

An inquest in July 2024 found that neglect had contributed to his death.

The coroner ruled that if the mother had been seen on arrival, she would have had a Caesarean by at least 1.25am, rather than at 2.02am.

If this had happened, the baby “would on balance have survived”, according to the coroner.

The panel also found that both Mrs Wood and Miss Duignan failed to respond to requests for help from the family.

It determined that they would have heard the patient and her family shouting based on the proximity of the room they were in to the midwives’ station.

The NMC said the actions of the midwives “were a breach of the fundamental tenet of the profession”.

Neither staff engaged from NMC proceedings.

In light of this, the NMC said there is a “high risk” of this conduct being repeated.

Both were struck off the register, meaning they can no longer work as midwives.