Two midwives are facing the end of their careers after failing to provide timely emergency care for two newborns, which led to the babies losing a significant chance of survival.
Jasper White, born in June 2019, and Margot Bowtell, born in May 2020, both died after being delivered at the Cheltenham Birth Centre, which is part of the Gloucestershire Hospitals NHS Foundation Trust. Midwives Hazel Williams and Lisa Land were on duty at both births. An investigation revealed they did not transfer the babies to neonatal intensive care in time, which could have saved their lives.
The Nursing and Midwifery Council (NMC) panel concluded on Tuesday that both midwives committed misconduct and were unfit to practice. They were also found to have falsified medical records, particularly concerning Jasper’s care.
Neither Williams nor Land attended or was represented at the hearing.
The Cheltenham Birth Centre, designed for low-risk pregnancies, did not have emergency facilities. In the event of complications, mothers were supposed to be transferred to Gloucestershire Royal Hospital, a 30-minute drive away.
Jasper’s health rapidly worsened after birth, but there was a 50-minute delay in transferring him to the neonatal unit. He died just 11 hours later. The NMC panel found that Williams, the senior midwife, failed to escalate the situation for a timely transfer. She was also found to have pressured Land to change Jasper’s condition in the medical records from “poor” to “good” days after his death, and to have added misleading entries.
Land was also found to have failed to escalate Jasper’s condition and had intended to mislead anyone reviewing the medical records.
In May 2020, Laura Bowtell, who was pregnant with Margot, experienced two episodes of bleeding during labor and repeatedly requested a transfer to the hospital. Despite this, the transfer did not take place. Margot was born not breathing and was rushed to the hospital, but passed away three days later.
The NMC panel found that Williams had ignored Bowtell’s requests and failed to transfer her to hospital care. When Margot’s heart rate began to decline, Williams also failed to notify the hospital receiving the baby. The panel further found that Williams had created a poor culture at the unit, where serious incidents were not shared or learned from.
Land, who was aware that Bowtell’s condition was not suitable for midwifery-led care, did not arrange for the transfer. The panel also found that Land made dishonest changes to the medical records, claiming inaccurate notes about blood staining and low maternal temperature. She was also found to have breached professional boundaries by sending WhatsApp messages to Bowtell without clinical justification.
Panel chair Derek McFaull stated that both midwives had failed to meet the professional standards required of them, mistreated their patients, and failed to demonstrate honesty. He added that their actions had contributed to Jasper and Margot losing “a significant chance of survival.”
McFaull also pointed out that both midwives tried to cover up their actions through “inaccurate or dishonest record-keeping,” which increased the risk of harm to other patients.
There was no evidence that either Williams or Land showed remorse or understood the full impact of their actions. The panel warned that they could repeat these mistakes in the future.
A decision on what sanctions the midwives will face is expected on Wednesday.
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