Tees’ Clinical Negligence team advocates for campaigning for patient safety concerning antenatal, maternity, and neonatal care.
BBC Panorama exposes maternity care failures
A BBC Panorama documentary aired on Monday, 29 January 2024, highlighting maternity care issues at Gloucestershire Hospitals NHS Foundation Trust, including the Cheltenham Birth Centre.
A tragic loss: Margot Frances Bowtell
Tees’ client, Laura Harvey from Gloucester, lost her baby, Margot Frances Bowtell, at just three days old. Laura recalls her experiences with Gloucestershire Hospitals NHS Foundation Trust in 2020 after the hospital admitted liability for failures in her care that led to Margot’s death.
Margot was born on 14 May 2020 at the midwife-run Cheltenham Birth Centre and passed away on 17 May 2020 due to a hypoxic brain injury sustained during delivery.
Investigation and accountability
The care Laura and Margot received was provided by two midwives, who are no longer working at the Trust. Both midwives are now under investigation by the Nursing and Midwifery Council (NMC) regarding the circumstances surrounding Margot’s death.
A report by the Healthcare Safety Investigation Branch (HSIB) identified multiple care issues, including a failure to update Laura’s risk assessment after she experienced reduced fetal movements and a bleed at 34 weeks pregnant. As a result, Laura was admitted to a midwife-led, low-risk ward instead of the consultant-led unit she needed.
Missed opportunities for intervention
During labor, Laura experienced further episodes of bleeding. However, these were not escalated to the on-call obstetricians, nor was the information properly handed over between midwives during the shift change on 14 May 2020. HSIB concluded that a referral to the obstetric-led unit for continuous monitoring of Laura and Margot was necessary.
Gloucestershire Hospitals NHS Foundation Trust admitted liability for failures in Laura’s care that caused Margot’s death.
Legal advocacy and expert commentary
Sarah Stocker, Associate at Tees, stated:
“The midwives involved did not follow both national guidance and the hospital’s own clinical guidance on several occasions during Laura’s labor. If the midwives had acted in the hours before Laura gave birth, she would have been transferred to the appropriate ward for obstetric-led care. With continued monitoring, Margot would have been delivered at the first sign of fetal distress and would still be with us today.”
Laura Harvey’s perspective
Reflecting on the midwives and ongoing investigations, Laura Harvey said:
“As a family, we want and more importantly deserve to know why both midwives made the decisions they did and why they chose to directly ignore and not follow the Trust’s own standard practice procedure. It was not just one point where they failed to escalate my care; it was a series of failures.”
A positive experience after loss
In December 2023, Laura safely delivered a baby daughter at Gloucester Hospital, under the care of the Rainbow Team. This time, she experienced exceptional care.
Calling for safer maternity practices
Laura Harvey continues to advocate for better maternity care, emphasising the importance of following safety procedures:
“There are midwives who are working hard and following the safety procedures in place to bring babies into our world, going above and beyond to help everyone.
It should not be a postcode lottery where you give birth and the care that you receive. Midwives and doctors need to follow the national set of safety procedures.
We need to highlight the Trusts that are excelling and share knowledge with those currently struggling. Most importantly, we need to share and learn from what happened to Margot to prevent it from ever happening again.”
