Mother gave birth in her car after maternity service errors

What happened

Mrs L went to the Trust's birth centre late in the evening because her waters had broken.

A midwife examined Mrs L and did not think that she was in established labour. She advised Mrs L to go home. However, she did not speak to Mrs L about how she was feeling or observe how she was coping with contractions. The midwife also did not take into account the fact that, because Mrs L's waters had been broken for a long time, she was going to need to attend hospital for antibiotics at 2am (two hours later) even if she had not given birth by then. Mrs L left the birth centre and went home.

Later that night, Mrs L telephoned the Trust because she felt that her contractions were stronger. However, she was again advised not to go in. At around 2am Mrs L and her husband set off for the hospital for Mrs L to have antibiotics. However, Mrs L's labour progressed and she gave birth in the car on the way to the hospital.

What we found

The birth centre did not properly assess whether Mrs L was in labour before it concluded that she was not and sent her home. The Trust's communication with Mrs L was not of an adequate standard because it did not take her views and reluctance to go home into account, and it gave her incorrect advice.

The Trust did not take Mrs L's individual circumstances into account. Mrs L would need antibiotics from the hospital if she did not give birth within two hours of arrival at the birth centre. Given the distance between Mrs L's home, the birth centre and the hospital, this essentially meant that Mrs L was going to spend much of the next two hours travelling.

Mrs L should either have been admitted to the birth centre, or advised to go directly to hospital from the centre. The cumulative effect of the failures in care led to Mrs L giving birth in her car, as there were repeated missed opportunities for appropriate care that could have prevented her traumatic experience.

Putting it right

The Trust acknowledged its mistakes and apologised. It paid Mrs L compensation of £1,000 in recognition of the distress she experienced and drew up an action plan that showed what service improvements it would put in place to prevent a similar situation from happening again.