Baby death was not a ‘serious incident’

The death of a baby at a scandal-hit hospital was not classified as a ‘serious incident’ by midwives, a tribunal heard.

Lisa Granville and two other midwives are accused of failings in their care after two neo-natal deaths on the overidge Ward at Princess Elizabeth Hospital (PEH), Guernsey.

Classifying the first death as an ‘SI’ may have prevented the second death in 2016, it is claimed.

Lisa Stephens, head of midwifery at the hospital until 2016 said: ‘These incidents are rare, especially in Guernsey.

‘The fact is this was a very serious incident. Questions should be asked by management and supervisors when they happen.

‘The question should have been asked “is this a serious incident”?’

Charles Elton, defending Granville, suggested she was correct in not filing the death of Baby B as a SI based on that flowchart procedure.

But Ms Stephens said: ‘You ask whether it is an SI before you look at the flowchart.

‘The flowchart is there to facilitate debate and discussion on the incident not to determine the outcome.’

Mr Elton said that according to the chart Ms Granville had acted correctly in not classifying the death as an SI.

Mrs Stephens said: ‘I go back to my first point: do you consider this as an serious incident and that supercedes any flowchart.

‘The question should have been asked “is this a serious incident”?’

Mr Elton said: ‘But does responsibility for launching a serious incident investigation fall with the obstetrician?’

Mrs Stephens responded: ‘No, midwives and risk management midwives can suggest it be classed as an SI.

‘I think the maternity team and the head of midwifery should have been asking those questions.’

Mrs Stephens also confirmed that she knew about the practice of ‘verbal orders’ by midwives to use drugs which should have been decided by a senior doctor, from her time on the maternity ward.

She said: ‘Verbal orders were being taken for many drugs, including Syntocinon in labour.’

Granville, Tuija Roussel and Antonia Manousaki were on duty when the child, referred to only as Baby A, was born just after midnight on 30 January 2014.

The desperately ill baby required resuscitation and died on the afternoon of 30 January 2014.

A subsequent investigation revealed concerns about a similar case of another child, referred to only as Baby B, who died in September 2012.

The tribunal has heard Granville spent ‘barely any time’ reviewing the notes of one death before declaring that the care provided was adequate.

The tribunal also heard that midwives regularly gave patients the drug Syntocinon during birth without speaking to a consultant, a practice described as part of a culture called ‘The Guernsey Way’.

Following the death of Baby A on January 30 2014, a subsequent investigation revealed concerns about a similar case of another child, referred to only as Baby B, who died in September 2012.

The NMC claim that, had the death of Baby B been adequately investigated, the death of Baby A ‘may have been prevented.’

Baby A’s father has told the panel that Syntocinon, a synthetic form of naturally-occurring hormone oxytocin used to facilitate childbirth, was administered without his partner’s consent.

Granville, who is present and represented, admits failing to identify inadequate midwifery care in relation to the administration of syntocinon and management of the CTG trace.

She also admits her investigation into the death of Baby A was inadequate, but denies all other charges.

Manousaki, who is present and represented, admits administering syntocinon to Patient A without a written prescription and in the presence of mild fetal heart rate distress.

She also admits failing to appropriately question the rate at which syntocinon was administered and failing to seek a review from a consultant after a ‘suspicious’ CTG trace, but denies administering it without patient consent and denies failing to challenge a culture of midwives acting outside the scope of their practice.

Roussel, who is present and represented, admits administering syntocinon without a written prescription or medical review and admits those actions increased the risk of harm to Patient A and/or Baby A.

She also admits participating in inappropriate working practices, such as midwives accepting verbal orders and seeking to avoid contact with obstetricians at night, but denies all other charges.