Baby death was not properly reported for two years

A care regulator investigating baby deaths found ‘systemic problems’ at a scandal-hit Guernsey hospital.

Maria Patterson, senior midwife for south west England, said the deaths were not even notified to the proper authorities for two years.

She told the Nursing and Midwifery Council that nothing was done to change procedures after the deaths of two babies on the Loveridge Ward at Princess Elizabeth Hospital.

Lisa Granville is one of three midwives are accused of a series of blunders in the care of the expectant mother and child in 2012.

Granville, Tuija Roussel and Antonia Manousaki were working on the Loveridge Ward at Princess Elizabeth Hospital (PEH), Guernsey 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.

Granville reviewed both cases and wrongly concluded no further action was necessary.

Representing Ms Granville, Charles Elton said Ms Patterson that ‘she was not in a position to label hospital management as poor’.

Ms Paterson said: ‘I would disagree with that. By August 2014 it was clear there were systemic problems in relation to the supervisor.

‘It became clear that there were systemic concerns and there was a lack of supervisory investigation into the deaths.

‘It was clear that the safety net was not working.’

Ms Patterson said the death of a baby in 2012 was not investigated until two years later.

Ms Patterson said: ‘I think that this case should have been investigated in by the LSA (Local Supervising Authority) in 2012.

‘But the LSA was unaware of a baby death in Guernsey.’

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.

Ms Granville reviewed both cases and wrongly concluded no further action was necessary.

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.

The hearing continues.

ENDS