Poor midwifery care meant woman delivered baby herself

What happened

Miss J was pregnant for the first time, had irregular contractions and was admitted to the Trust's maternity unit late one night in winter 2012. Midwives sent her home just after midnight saying that she was not in established labour (4cm dilation with regular painful contractions).

Miss J's contractions continued and in mid–afternoon that same day she delivered a healthy baby at home before either the ambulance crew or midwife arrived. When the midwife came, she failed to explain the third stage of labour (what happens immediately after the birth) to Miss J and did not have the drug needed to make sure the placenta was delivered safely.

The midwife also did not make regular clinical observations or keep accurate and thorough records, so that when Miss J's condition started to deteriorate and she started to lose blood, she did not recognise that this was becoming an emergency. Miss J continued to lose blood and reported feeling unwell, but the midwife failed to take prompt action to make sure Miss J's condition did not get worse.

Eventually the midwife called an ambulance and Miss J was taken to hospital. When she arrived she was told her baby would be fed once she was settled. Miss J said that staff gave her confusing information about her baby's blood sugar level and the need for a drip. She believed midwives failed to consider his low birth weight and so misdiagnosed his blood sugar level.

What we found

We partly upheld this complaint. Miss J had been rightly discharged from the maternity unit because she was not in established labour.

However, the midwife failed to explain the options for managing the third stage of labour, and did not recognise the need for giving Miss J the drug oxytocin. Overall, the midwife failed to plan her care, including delivering the placenta. She did not carry out thorough clinical observations, so that when an emergency situation arose she did not recognise it. There was also evidence of poor record keeping.

There was no evidence to support Miss J's view that the Trust overlooked her baby's birth weight when she was readmitted to hospital or that his blood sugar was misdiagnosed.

Putting it right

The Trust apologised to Miss J for the impact of the service failings we identified and paid her £700 in recognition of the suffering these failings caused.

The Trust explained the action it had taken to learn from these events, particularly in relation to communication and record keeping.