Baby died at Wirral hospital after midwife failed to diagnose life-threatening condition

A colleague raised the alarm after struggling to record the baby’s heartbeat.

A baby died after a Wirral midwife failed to recognise a life threatening condition and did not inform colleagues of issues surrounding a high-risk patient, a report has concluded.

A Nursing and Midwifery Council report said that Mr Clinton ‘failed to identify and or recognise when Baby A was suffering a fetal bradycardia’ and ‘failed to adequately escalate concerns regarding Patient A’s condition’ when dealing with a high-risk mother at Wirral University Teaching Hospital in December 2019. As a result of this, a condition that led to the baby’s death seven days later was not prevented.

Mr Clinton assessed patient A, who was 37 weeks pregnant and booked in for an elective caesarean three days later, and began electronic monitoring of Baby A’s heart rate 12 minutes later for 40 minutes. It was determined patient A was not yet in labour, but her pregnancy was high risk as a result of her previous obstetric history.

The midwife informed a colleague, referred to by the NMC as Witness 1, that patient A’s contractions were getting stronger and she was vomiting. Mr Clinton did not inform his colleague of any concerns with mother or baby at the time.

The report found there was ‘difficulty in recording [the baby’s] heartbeat’ but that the midwife did not inform colleagues and believed the issues were due to the mother vomiting.

A colleague then raised the alarm after struggling to record the heartbeat and then realising the baby had a very low heart rate, known as bradycardia.

The baby was then born after an emergency caesarean section in the operating theatre, in a very poorly condition.

A Coroner’s Report found that Baby A passed away from ‘natural causes contributed to by the delay in recognising and diagnosing bradycardia.’

Wirral University Teaching Hospital. Image: Google
Wirral University Teaching Hospital. Image: Google
Wirral University Teaching Hospital. Image: Google

In a reflective statement read to the panel, Mr Clinton, who was not present, apologised for his failures. It said: “The effect of this incident on the family concerned is obviously catastrophic and I can’t begin to imagine what they have been through in the past three years and also the effect that it will have on them for the rest of their lives. There is also a wider effect to consider, the impact of an incident like this on extended family and friends who may well lose faith in the trust concerned.

“There is also the damage that an incident such as this can have on the reputation of the midwifery profession, public trust in the profession to deliver high standards of care may be lost. I constantly reflect on this case and how things could have been different for this family and I hope they are able to move on with their lives.

“I have a deep sense of regret for the events of that day and the eventual outcome, it’s an outcome that potentially could have been avoided and I can only offer my sympathy to the family concerned.” Despite Mr Clinton’s contrition, the report said both parents impacted by the incident had their confidence in the healthcare profession undermined as a result of his care.

A three-person panel said Mr Clinton’s conduct “breached the fundamental tenets of the midwifery profession and therefore brought its reputation into disrepute. They found his fitness to practise was impaired.

He is free to continue as a midwife – though is not currently employed as one – but must abide by a conditions of practice order which limits the number of providers he can work for and must inform all employers of his status. Mr Clinton must also be supervised any time he is working by a a registered midwife of Band 6 or above and keep a reflective practice profile.