County NHS accepts liability for death of three-day-old baby girl
ABABY who died three days after her delivery at a midwife-run NHS birth centre in Cheltenham was failed by shortcomings in care from Gloucestershire Hospitals NHS Foundation Trust.
The Trust has accepted liability for the death of Margot Frances Bowtell, who was born on May 14, 2020, and died of a hypoxic brain injury three days later.
After the announcement, Margot’s mother Laura Harvey spoke of her devastation over losing her daughter, saying the pain would remain with her forever.
“The personal guilt I carry will always stay with me, even knowing now it was nothing I did wrong,” said Laura, 35.
“Saying goodbye to our beautiful baby girl is the hardest thing I have ever had to do and knowing it could have been prevented is even harder to live with.”
Now Laura wants to raise awareness to help ensure similar midwifery failures do not cause other families the same grief as she and partner Craig Bowtell have had to go through.
“I want to make sure the Gloucestershire Trust implements all the safety recommendations that our investigation unearthed and help prevent the devastating loss of another baby the way in which it happened to Margot,” she said.
Sarah Stocker, of law firm Tees Law, who represented Laura, said: “Gloucestershire Hospital NHS Foundation Trust could have averted this tragic outcome if warning signs during pregnancy and labour had been recognised and properly acted upon.”
Specifically, the Trust admitted that the presence of blood-stained liquor noted during labour should have led to a referral to the obstetric team and that failure to do so was a breach of duty, a statement from Tees Law said.
Had Margot undergone obstetric review when the presence of bloodstained liquor was noted, her delivery would have been expedited and she would still be here today.
After many hours of painful and traumatic labour, Margot was delivered through an episiotomy in a poor condition and rushed for resuscitation by midwifery staff, assisted by paramedics from a waiting ambulance.
Margot was eventually transferred to Bristol Neonatal Intensive Care Unit, where she remained intubated and ventilated for three days.
An MRI scan of her head showed an “acute near total hypoxic ischaemic insult” from which she would not be able to recover.
Eventually, Laura and her family had to make the heart-breaking decision to stop active treatment and withdraw life support.
Margot was moved to a room where the family could spend time with her and she died on May 17, 2020, at three days of age, with her parents present.
Following the statement by the Trust admitting liability, Ms Stockton said: “There were failures by the midwives during Laura’s labour, who failed to follow the Hospital Trust’s own guidelines and national guideline on multiple occasions and transfer Laura and Margot for consultant-led care.
“Had this been done, Laura’s problematic labour would not have developed into this crisis and Margot would be here with her family.
“The family sincerely hopes that the hospital takes heed of the critical Healthcare Safety Investigation Branch report on the incident and prevents such an avoidable disaster befalling any other family in the future.”
Trust acting chief executive, Professor Mark Pietroni, said: “We are deeply saddened by the tragic circumstances surrounding the death of baby Margot and our thoughts and condolences remain with the family.
“The Trust acknowledges that there were failures in care, which were fully and independently investigated by the Healthcare Safety Investigation Branch (HSIB).
“We have fully accepted and implemented the safety recommendations made by the HSIB in their report to ensure that all possible lessons are learnt from Margot’s tragic death.”
We are deeply saddened by the tragic circumstances surrounding the death of baby Margot and our thoughts and condolences remain with the family
Professor Mark Pietroni