‘My child was drowning’: life and death on an English maternity ward
If Charlotte Bassett had known that her daughter Norah’s life would be numbered in hours and minutes, not decades and years, she’d never have left her side. But she didn’t. So Charlotte went to have a shower after Norah’s birth on 12 April 2019. When she came out of the shower, a junior doctor was assessing Norah, who was being looked after by her father, James Bassett. The doctor gave Norah the all-clear, and left them alone.
The maternity unit at the Royal Hampshire county hospital in Winchester was busy that evening. When the night shift came on duty, a midwife introduced herself. “She was very brusque,” Charlotte, 37, a data manager, remembers. “She said, ‘We’ve got too many people here. I’ve got this and this to do.’” Charlotte tried to breastfeed Norah, but she wasn’t latching. The midwife told Charlotte to cup feed her with formula. She didn’t stay to watch. Charlotte poured milk from a cup into Norah’s rosebud mouth. Blood came out. It was staining the muslin. The midwife didn’t seem concerned.
“I was drowning my child, who was drowning in her own blood. And there was no one there to say: this isn’t normal,” Charlotte says. We are sitting in the Bassetts’ house in Eastleigh. By the window is a display case. It has photos of Norah in it, locks of her hair, her handprints. Her ashes.
“She’s wonderful, isn’t she?” says James, 40, a travel industry manager, gesturing to the cabinet. “I’m so proud of her.”
At about 9.30pm, nearly two hours after the doctor assessed her, Norah started grunting. “I’m sorry,” says James. “I can’t repeat the sound.” Charlotte went out to the desk. The midwives ran to Norah. “It was a shit show,” says
Charlotte. “They were making notes on scraps of paper.” Norah was taken to neonatal intensive care.
As they waited for news, the same midwife came back. “She went, ‘Oh, it’s so busy tonight. I’ve got all these sheets to wash,’” says Charlotte. James went into the bathroom. He got down on his knees and prayed to a God he didn’t believe in to trade places. Let Norah live. Take him instead.
Norah died shortly before midnight. “The scream I let out,” says Charlotte, softly. “They do it really well on TV sometimes.”
The Health Services Safety Investigations Body (now HSSIB but at the time known as HSIB or Healthcare Safety Investigation Branch), which investigates patient safety in English hospitals, produced a report into Norah’s care in 2020. One sentence leaped out to Charlotte and James. “An upper airway event (such as occlusion of the baby’s airway during skin-to-skin) may have contributed to the baby’s collapse.” In other words, it was possible that Charlotte might have smothered her daughter.
“So Charlotte spent four years in agony,” says James, “thinking it was her.” ***
Dr Martyn Pitman remembers the night Norah died, because it was unusual. A crash call, for a baby born to a low-risk mother. It played on his mind, because eight days earlier, on 4 April 2019, Pitman, a consultant obstetrician and gynaecologist, had presented proposals for enhanced foetal monitoring to a meeting of the maternity unit’s doctors and senior midwives. Pitman, 57, who is an expert in foetal monitoring, felt the proposals would prevent more babies suffering brain injuries at birth. “We’re not that good at detecting the high-risk baby, in the low-risk mum,” he says.
Another doctor would later characterise the meeting as “hideous … hands down the worst meeting I’ve ever been to. Martyn … was being set upon.” A midwife felt the animosity in the room was “personal towards Martyn”, and was “appalled” by the “unprofessionalism that I saw from my midwifery colleagues”.
Of this meeting, a Hampshire hospitals NHS foundation trust (HHFT) spokesperson says there was evidence of “tension on both sides”.
Derinell Haikney, a midwife, was not invited to the meeting. But she says she overheard some senior midwives as they prepared to go in. “They said, ‘He won’t know what’s hit him.’ They’d written all over his guidelines in red pen.”
Relations between Pitman and some of these senior midwives was fraught. Most of them didn’t work clinically on a day-to-day basis – “on the shop floor”, in NHS speak – but ran HHFT’s maternity services across three sites in Basingstoke, Winchester and Andover. A month earlier, on 7 March, Pitman had met the trust’s head of midwifery to discuss his concerns.
“The morale of the midwives was deteriorating,” says Pitman. “Sick leave rates were going up. We were starting to have challenges getting inductions done on time. You’d come in to do elective C-sections and be told you couldn’t do them because we didn’t have a midwife for your surgical list. If we didn’t do something, we were going to start to get avoidable disasters.”
The problems started in 2012, when the Basingstoke and North Hampshire hospitals NHS foundation trust merged with the Winchester and Eastleigh healthcare NHS trust. In Winchester, staff felt it wasn’t a merger, but a takeover. Midwives in management positions tended to come from Basingstoke. They introduced an unpopular oncall policy. Staffing was a problem, and some midwives felt that vacancies weren’t being advertised fairly. In 2019, some Winchester midwives took their concerns to Pitman, and he relayed these concerns to the head of midwifery, including telling her that she might be subject to a no-confidence vote.
But to the trust’s head of midwifery, the 7 March meeting felt like a personal attack. She left in tears. Six weeks later, on 21 April 2019, along with the joint deputy heads of midwifery and one consultant midwife, she made a formal complaint of bullying and harassment against Pitman.
An investigator was brought in to assess their complaints. They told her that they felt Pitman did not respect their professional expertise. He was hostile in meetings. He wrote ranting emails. (“HOW ARE YOU PROPOSING TO STAFF THIS SERVICE,” read one.) He gossiped about them. “He’s very good at bamboozling people with evidence that isn’t necessarily valid to get his way,” said one complainant. The issues were longstanding. In August 2018, some of these senior midwives had a meeting to discuss their concerns about Pitman and other obstetricians with hospital management.
The outside investigator also spoke to other doctors. While none described Pitman as a bully, they said he could be uncomfortably forthright, even antagonistic. His boss described him as someone who wasn’t good at seeing other people’s points of view, but said that “his heart is absolutely in the right place. It’s always about patient care”.
The investigator concluded that Pitman wasn’t deliberately trying to bully or harass these senior midwives, but that his “style of communication is a challenge”, and this had significantly harmed his complainants.
But the investigatoralso found evidence that Pitman wasn’t solely the problem. She concluded that some of the senior midwives who had made