Award-winning midwives are struck off after two new child infants died and so they tried to cowl up their errors

Award-winning midwives who delayed calling an ambulance for two newborns who later died in hospital and then tried to cover it up have been struck off.

Hazel Williams and Lisa Land have been thrown out of the profession following the deaths of Jasper White and Margot Bowtell.

Both babies were seriously ill when they were born at the Aveta Birth Centre in Cheltenham, Gloucestershire, a disciplinary hearing was told.

But senior midwife Miss Williams – who led the unit – and Mrs Land failed to respond quickly enough and call an ambulance for them to be taken to the nearest hospital.

The pair then altered medical records to make it appear as though Jasper – who was struggling to breathe and was a ‘pale colour’ – was in a better condition than he was.

They were hauled in front of a Nursing and Midwifery Council (NMC) committee for not providing ‘basic midwifery care’ and dishonesty.

Miss Williams and Mrs Land, who have been midwives for 34 and 16 years respectively, have both been struck off the register.

The tribunal heard that the two women worked at the midwife-led unit for low-risk pregnancies and that the nearest hospital was the Gloucestershire Royal Hospital half an hour away.

On June 25, 2019, baby Jasper was born at the clinic, within minutes he was struggling to breathe.

However, an ambulance was not called until 50 minutes after his birth, including a 20-minute delay between Mrs Land deciding that he needed to be transferred and the emergency call being made.

It was not until an hour and a half after his birth that Jasper was officially transferred to the neonatal unit. He sadly passed away there the next morning from a lack of oxygen and a haemorrhage.

An expert witness told the panel that the delay ‘significantly shortened’ the chances of Jasper surviving, she said it was not certain he would have lived but the cause of his deterioration might have been reversed if he had been transferred to the neonatal unit faster.

She said Miss Williams should have ‘escalated’ Jasper’s treatment as soon as she realised he was struggling, just a few minutes after his birth.

The hearing was told that after Jasper’s death, Miss Williams told Mrs Land to change the ‘details of birth’ form from recording Jasper’s condition as ‘poor’ to ‘good’.

Miss Williams also made changes to other statistics on the record to make it seem like Jasper was in better health than he was.

The panel concluded it was ‘dishonest’ for the two women to make these changes and that they intended to ‘mislead’ anyone who checked the records.

Just a few months before, both of the midwives had won Gloucestershire Hospitals’ award for Best Quality Improvement Project for Implementation of a Continuity of Care model at Aveta Birth Unit.

On May 14, 2020, nearly a year after Jasper’s death, Laura Bowtell gave birth to her daughter, Margot, at the same centre.

Mrs Bowtell requested an ambulance three times in the hours leading up to Margot’s birth and it was not until the final time she asked that Miss Williams to get a colleague to make the call.

However, at that point Margot’s head could be seen and it was too late for the pair to be transferred before Mrs Bowtell gave birth at 1:30pm.

Margot required immediate resuscitation when she was born and once at hospital she was taken to the neonatal intensive care unit but, sadly, she passed away three days later due to complications from oxygen deprivation.

During the birth her foetal heartbeat dropped below 60bpm which should have prompted an emergency response from the whole unit, led by Miss Williams as the lead midwife.

This did not happen and the panel heard that Miss Williams used the regular call bell to ask for help and not the emergency bell because it was regularly switched off as she wanted the centre to be a ‘home from home’ without alarms going off.

Miss Williams also did not give a handover to the receiving hospital to alert them to the baby’s low heart rate, the hearing was told.

The panel heard that in the weeks leading up to the birth Mrs Bowtell had a minor haemorrhage and reduced foetal movement which should have prompted a risk assessment and her transfer to an obstetric-led unit by Mrs Land, who was her named midwife at the time.

In the early hours of May 14, during labour, Mrs Bowtell had blood in her amniotic fluid and a low temperature both of which should have prompted Mrs Land to call an ambulance, the hearing was told.

Instead, she handed Mrs Bowtell’s care over to Miss Williams just before 8am who an expert witness said ‘failed’ to fully check the notes made by Mrs Land about the bleeding and also did not escalate treatment.

The panel was told that an internal investigation had revealed that Mrs Land was not aware that a below average temperature is a risk factor for sepsis.

Almost a year later, in March 2021, Mrs Land sent a WhatsApp message to Mrs Bowtell to ask her how she was, a move Mrs Bowtell told the panel ‘filled her with anger’.

Striking off the two midwives, the panel said they had ‘breached fundamental tenets’ of midwifery and their actions could discourage the public from seeking services at a birthing unit.

They said: ‘[Their] misconduct has breached fundamental tenets of the midwifery profession, particularly in relation to not transferring Baby A or Patient B which the panel considered to be fundamental basic midwifery care.

‘Further, the panel considered [their] attempt to cover up [their] actions with inaccurate and dishonest record keeping to be a breach of the fundamental tenets of the midwifery profession and therefore brought its reputation into disrepute.

‘It was of the view that such acts or omissions could discourage members of the public to seek midwifery services at a birthing unit.’