AN INVESTIGATION was launched after the death of a baby girl at the Royal Bolton Hospital.

The internal probe found that the midwife involved in the birth was at fault after departing from 'accepted and known procedures' in relation to the monitoring of foetal heart rates.

The parents of the baby girl, from Bolton, have received the results of the Serious Incident Report – carried out by Bolton NHS Foundation Trust.

It states that the current Trust policy for monitoring foetal heart rates is out of date and should have been updated before the tragic incident occurred.

The baby's devastated mother, aged 38, who does not want to be identified, says she feels 'completely let down' by the people she trusted to keep her child safe.

The Trust has now put together an action plan.

Speaking after reading the report, the mother said: “We felt completely let down by the very people we had put our trust in to keep us and our baby safe, the NHS.

"They had told us all the way through that there was nothing untoward and they didn’t know why this had happened, but then to receive this report, we were totally unprepared for it.

“We have always believed that there is no such thing as bad people, just bad systems.

“We do not think that the midwife did anything that day that she hadn’t done before — we think it was just common practice that the midwives had their own unspoken way of doing things — the fact the policy was outdated means we have to blame the policy makers, not her.”

She also criticised the fact that an external review has not taken place as well as the bereavement service her family received after the tragedy.

She added: “We feel like we have been dropped like a hot rock. I was discharged, full of breast milk and no baby to feed or love. I was offered no advice or help and had to seek it out myself.”

The mother went into the hospital’s birthing suite in late June, for a midwifery-led birth.

Her baby girl was born shortly after midnight with the umbilical cord tied loosely around her neck and in a 'very poor condition.'

She required resuscitation and was immediately transferred to the neo-natal unit where she died in early July from an acute anoxic episode — where the brain is starved of oxygen.

The Serious Incident Report states that during labour, there were recorded incidents of foetal tachycardia (abnormally high heart rate) and foetal bradycardia (abnormally slow).

Referring to the tachycardia, the report states: “This was recorded soon after handover and the midwife did not consider increasing the frequency of monitoring the foetal heart rate.

“She did not seek a second opinion as to whether the mother should remain in the birthing suite solely in the care of the midwifery team or to be transferred to consultant led care.”

It adds: “The midwife did not consider recording the foetal heart continuously to establish an accurate baseline.”

With regard to the abnormally slow heart rate being recorded the report states that the Trust’s policy for monitoring foetal heart rate is out of date and should have been updated before March, 2015.

The Trust’s Birth Suit Guidelines state that if any deviations from normal occur for a mother or baby, the midwife will organise a transfer to a consultant and the episode of tachycardia was an indication for this to happen.

Referring to the National Patient Safety Agency’s guidelines, the investigation found that “suboptimal care” occurred during labour due to “human error, departing from accepted and known procedures.”

Among a host of recommendations, the report suggests a retrospective audit of Birth Suite deliveries from April to September, a review and updating of the policy for foetal monitoring and to consider disciplinary action for the midwife involved.

The Trust has refused to comment on whether any disciplinary action is taking place but said it has produced a detailed action plan.

Trish Armstrong-Child, director of nursing and midwifery, said: “The loss of a baby is a tragedy whatever the circumstances and we feel deeply for this couple.

“We believe that whenever anything has gone wrong, it is the right thing to share with the family concerned, any internal review undertaken to look at the circumstances, even though this can be difficult and painful for everyone - this is what we have done.

“We have produced a detailed action plan which includes proactively holding a retrospective audit into six months of births, to analyse practice — this audit has begun but has not yet been completed.

“We have checked and updated the relevant policies, however no changes were required and we are increasing the bereavement support available to any parents in these circumstances.”

The mother involved said she now hopes any cases highlighted by the ongoing audit will be highlighted and that families will be informed.

Sophie Fox, the clinical negligence lawyer with JMW Solicitors who represented the parents, said the Trust’s report and apology was “some comfort” to the family.

“It has helped them come to terms with what’s happened to a degree but it should not be forgotten that it underlines how proper clinical practices were not observed to the extent that something went very terribly wrong.

“The family in this case is eager to ensure that new and more rigorous guidelines are put in place to avoid the risk of other parents suffering as they have done.”