In the same week that we find out about 3 more maternal deaths at Northwick Park, the maternity unit which was until only recently under special measures for 10 previous deaths, there is a report about a baby’s death at an adjacent unit ” Mothers heartbreak: How 30 blunders by hospital killed my newborn baby”.
It’s difficult when you read articles in newspapers, obviously the reporter has interpreted the report that the press association has issued and highlighted the issues which s/he feels are important. The problem with them deciding what to publish is that it is often misleading as they don’t understand the importance of seemingly minor facts.
Nothing can ever take away from the absolutely appalling errors made by the person who would have made the decision about whether the syntocinon should have been stopped, left at the same rate or increased. No amount of money can ever compensate the parents for the needless death of their son due to someone failing to make the decision to intervene and deliver the baby by caesarian, but, who is this person? In the article the expert witness apportioned blame “‘I would have expected the registrar, other doctor or a midwife to have appreciated the deterioration in this baby’s condition in labour.” So, we know who to heap the blame on, and commentators have been, rightly, quick to do this. However, if you read the article it also says that “The evidence of Alwyn’s failing heart rate was recorded in medical notes and reported to senior staff 11 times in seven hours – yet no one understood the baby’s life was in danger”. What are they talking about? If it was reported 11 times then someone was not happy with the CTG, and who was that someone? The midwife caring for Mrs Calloway. So, the midwife reports it, what should happen? The situation should be reviewed by a senior midwife and the registrar. Obviously the registrar was asked to review the monitoring as “A specialist registrar even used the cardiotachograph (CTG) recording of the baby’s heart rate as an example of a normal labour as he taught a student – oblivious to the fact that Alwyn was being fatally brain-damaged”, do I blame the midwife? No. There is little that can be done if an obstetrician does not agree with your concerns about how a labour is progressing, a midwife cannot perform a caesarian.
I have tried to leave a comment to this effect but the Daily Mail is obviously not interested in such minor details as it hasn’t been published!
CTG is not a cardiotachograph, it is a cardiotocograph. Minor error I know but it is the small things that build the whole picture, and if they are even slightly wrong then the true story is not told.