Willow Davies

Bedford Hospital NHS

NHS Trust

Response by Bedford Hospital to HM Senior Coroner’s Regulation 28 Report dated 21
April 2015

The report drew attention to three matters of concern. These are listed below, together with
the Trust’s response to each

1. That.a newly qualified Midwife was allocated to deliver a baby when, during the
course of her training and her practice since qualifying, she had never assisted with
the resuscitation of a new born baby. The Midwife had no further support.

A newly qualified midwife enters onto the Nursing and Midwifery Register once the required
standard in all aspects of training are met. This assessment is carried out by the training
University.

At the point of registration a midwife is deemed competent in all aspects of midwifery care
including resuscitation of the new born. The Nursing and Midwifery Council Standards for
pre-registration Midwifery Education states that upon entering the professional register,
midwives are expected to “examine and care for the new born infant: to take all initiatives
which are necessary in cases of need and to carry out where necessary immediate
resuscitation” (NMC, 2009).

There are many clinical scenarios that midwives are taught to manage during training that
they may or may not encounter during the course of their work. It is usual that within modern
pre- registration training and post registration practise, a practitioner acquires the necessary
clinical skills and knowledge by the means of simulation scenario- based training. This is a
robust method of training within pre-registration midwifery programmes generally, with
competence formally assessed and evidenced.

The incidence of term babies requiring extensive resuscitation is rare. Therefore the majority
of midwives are highly unlikely to experience this actual situation and some may not do so
throughout the course of their professional career.

Neonatal resuscitation through assimilation assessment forms one part of the interview and
selection process for recruiting all midwives to the maternity unit at Bedford Hospital.

All midwives subsequently employed within the Maternity Unit are required to attend
mandatory annual training in resuscitation, to ensure that their knowledge and skills are up
to date. This includes a refresher of theory and simulation (practical) training using
mannequins and resuscitation equipment, under the expert supervision of accredited
PROMPT (PRactical Obstetric Multi-Professional Training) trainers. This session is delivered
through a well-established roiling programme.

The Trust recognises that all new members of staff, whatever their experience, need a
period of time to become familiar with local procedures and practices. Within the Maternity
Unit at Bedford Hospital, an orientation period is allocated. ‘New starters’ unfamiliar with the
Trust (including a newly qualified midwife) would undertake this programme for up to a
month. Within this period, the new starter works with a nominated midwife for support and is
expected to complete a bespoke orientation programme, developed following discussion

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NHS Trust

with colleagues/ their supervisor of midwives, designed to meet their individual learning
needs.

A ‘new starter’ midwife has support from a number of sources that include a named
‘Preceptor Midwife’, a named Midwifery Team Manager and a named Supervisor of
Midwives. The midwife receives guidance in reflecting on their practise and feedback on
their performance colleagues at all levels, to ensure that they establish a cycle of learning
and personal development beyond registration.

The midwife involved in this case had successfully completed a Neonatal Advance Life
Support course towards the end of her pre professional training, in addition to the core
resuscitation training within the programme. The midwife’s resuscitation skills were tested at
interview as part of the recruitment process and she scored highly.

The Nursing and Midwifery Council (NMC 2008, NMC 2012) state that ‘a midwife must seek
assistance should she require help. This would be at any time during labour, delivery of the
baby and postnatal period’. It is the responsibility of the midwife to summon assistance as
the clinical situation warrants.

The midwife concerned worked as part of the Labour Ward team on duty that shift and had
access to the senior midwife in charge and the medical team for support. Each delivery room
has an emergency bell to summon help.

Since this very sad event the midwife has attended a further Neonatal Life Support (NLS)
course and has been subsequently asked to become a trainer by the Resuscitation Council
(GB).

The Trust considers therefore that the systems and processes that it had and still
does have in place in relation to this concern meet national requirements. Practices
are in line with practices in other maternity units. This minimises the risk from lack of
‘hands on’ practical experience and ensures that staff have the required skills and
support when needed.

2. That the allocation of women to midwives on a shift by shift basis did not. and does
not, take into account the experience of the individual midwife.

There is a senior midwife in charge of each shift in Delivery Suite, often without a case load
of their own. He/she risk assesses the complexity of the case mix of women/patients at
every handover, using the SBAR (Situation, Background, Assessment, Recommendation)
tool and allocates the care of women accordingly, taking into account staff experience,
competencies and confidence. The position is continually assessed throughout the shift,
taking into account such factors as admissions to the Delivery Suite, clinical complications
developing during delivery, the increasing complexity of workload and the available capacity
within the unit.

Reviews are recorded 4 hourly using a proforma developed by the former National Patient
Safety Agency (NPSA) — copy attached

The Trust’s Senior Midwife in Charge Policy (copy attached) state that the role is to:

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“allocate women on the Delivery Suite to the care of specific midwives according to the
skill mix and complexity of the woman’s needs. He/she will be aware of any development
needs. The Senior Midwife in Charge should establish any support the midwife may need for
that allocation of work and ensure this is in place. Each midwife has a responsibility to inform
the Midwife in Charge if he/she feels unable to provide care competently and confidently and
within their knowledge base.”

The Nursing and Midwifery Council does not stipulate that a midwife must have a second
person in attendance at the time of the birth. When the Trust’s Head of Midwifery raised this
issue at a meeting of the Contact Supervisor of Midwives’ meeting in April 2015, it was
confirmed that this approach is replicated in maternity units across the East Midlands and
East of England region. In line with the Code of Conduct and local Trust policy, it is the
responsibility of the midwife to request support if he/she requires it.

Baby Willow's mother was classified as a ‘low risk’ case throughout her pregnancy and this
classification was not changed on her admission to the Delivery Suite or throughout labour.
The hospital Clinical Guideline for ‘Care of women in labour in all care settings’ ( copy
attached) fully describes the Care of Healthy Women and Babies in Normal Labour (Section
2).

Sadly, Baby Willow deteriorated following her birth and died.

The Trust is satisfied that the allocation of the new graduate midwife to this ‘low risk’
case was, as considered both at the time and on reflection post this event, to be an
appropriate decision. The Trust considers therefore that the systems and processes it
had and still does have in place in relation to this concern minimise the risk of
inappropriate allocation of staff.

3. The system of ‘Supervisors of Midwives’, as it operates at Bedford Hospital, is in

urgent need of review to ensure that it is working to support pregnant women and
midwives within the Trust

The statutory Supervision of Midwifery system in the Trust is modelled on the
recommendations in the Local Supervising Authority Standards for Supervision (2009). An
annual Supervision of Midwifery (SoM) Report is received by the Trust Board and Local
Supervising Authority for Midwifery and this demonstrates full compliance.

A SoM Information Leaflet, based on the NMC leaflet “Support for Parents - How supervision
and supervisors of midwives can help you “ (2009) is given to every pregnant woman when
she registers her pregnancy through a process called ‘booking’. This leaflet sign-posts the
family on how to access a Supervisor of Midwives and outlines the functions of statutory
supervision. Bedford Hospital SoMs have an ‘on call’ rota, covering 24 hours availability,
365 days a year, and may be contacted by both users of the service and staff working both
locally and regionally, for advice and support. The family in this tragic case had the
involvement of a SoM during and after the completion of the investigation and prior to, during
and since the Coroner’s Inquest Hearing.

A Local Supervising Authority (LSA) SoM Investigation was undertaken and an abridged
version of the report was made available to the family and the Coroner by the LSA.

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Bedford Hospital NHS |

NHS Trust

The LSA Midwifery Officer, NHS England (Midlands and cast), A is clear that the
Trust is compliant with Statutory Supervision and would raise any concerns that she had
directly with the Chief Executive Officer or Director of Nursing. To date, no issues have been
raised and she would be happy to discuss any further concerns regarding the SoM report
concerning this case or indeed statutory Supervision of Midwives generally. Her contact
details are:-

ae... Supervising Authority Midwifery Officer Telephone: P|

The Trust and the LSA officer therefore consider that the system of statutory
Supervision of Midwives operating at Bedford Hospital is working effectively to
provide support to both mothers and midwives.

Stephen Conroy
Chief Executive
June 2015

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