A heartbroken mum said she will suffer with for the rest of her life after the of her newborn daughter.
Laura Bowtell asked her midwives to call an ambulance for her and baby Margot six hours into the at the NHS's Cheltenham Birth Centre. However, Lisa Land wanted to use "oils" and different positions instead, and she only backed down after Ms Bowtell asked three times for paramedics.
By that time, Margot's heart rate had dropped and her life support was withdrawn three days later. Ms Land and another midwife, Hazel Williams have since been thrown out of the profession following the deaths of and Margot another newborn, Jasper White, at Cheltenham Birth Centre.
An independent investigation by the Healthcare Safety Investigation Branch took place into Margot's death. It is reported the investigation found the bleeding in labour meant Mrs Bowtell should have been transferred to Gloucestershire Royal Hospital sooner and it could have saved Margot.
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Striking off the two midwives, the Nursing and Midwifery Council (NMC) committee 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."
Mrs Bowtell - who used to work in aviation - now has a 10-month-old daughter who she had via C-section. She said, though, the "PTSD I have will stay with me for the rest of my life".
Speaking to , the 37-year-old mum added: "Margot would still be here and I wouldn't have to live with this for the rest of our lives." In both Margot's case and that of Jasper, 11 months prior, the midwives failed to call the ambulance soon enough, which had tragic consequences. The pair also altered medical records to make it appear like Jasper - who was struggling to breathe and was a "pale colour" - was in a better condition than he was.
"It was my first so you don't know what to expect. I completely put my trust in the midwives. She was very chilled, she kept telling me I was low risk," Ms Bowtell continued.
"They told me I would be transferred if I needed it and she was very confident in her ability to spot when that would be needed. When I went into labour at midnight, Lisa was on the night shift and I felt at ease. She was the main person throughout... She arrived and I couldn't keep anything down, I was running on empty. My contractions weren't giving me enough to push. She assumed all of this was normal.
"She should have transferred me to Gloucester. I first asked for an ambulance at 10am, I was exhausted. But she wanted to try lots of oils and things instead."
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.
In the early hours of May 14, 2020, 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.
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 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.
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