Midwife ‘misread’ monitor – inquest
8:43am Friday 26th October 2012 in News
A MIDWIFE has admitted she misinterpreted a monitor showing the heartbeat of a baby who went on to be born with brain damage.
Sandra Harrison, a midwife, has given evidence at the inquest of Mikhael Morales, who died when he was just 11 days old on August 15, 2009, at the Royal Bolton Hospital following complications during his mother’s labour.
Mrs Harrison said it was a huge shock that Mikhael was born unresponsive at 5.23am on August 4.
She said: “I was shocked when he was born. It was distressing but not as distressing for me as it was for the parents.”
Mrs Harrison agreed when the assistant coroner for Bolton, Kevin McLaughlin, asked if she now saw that she was misinterpreting what was on the cardiotocography (CTG) monitor, which records foetal heartbeat and contractions.
Staff had taken the rare step of closing the maternity unit before the incident because it was so busy.
Bolton Coroners Court heard yesterday that locum registrar Dr Anthony Madu said he was unable to review Sheryl Morales, Mikhael’s mother, who lived in Farnworth at the time, before she gave birth because he was “busy”, but prescribed drug Syntocinon to hasten her labour.
Mrs Harrison said: “Dr Madu said he wasn’t coming to Bolton any more because he didn’t like it. He said it was busy and he was always being asked to do something and was sick of midwives asking him for things.”
The court heard that Mrs Harrison had no option but to take the unusual step of caring for two women in labour rather than one.
She was juggling their care with answering the door to the unit, answering calls and making tea for angry relatives of a woman in the unit .
Dawn Johnston, director of nursing midwifery at Barts Healthcare in London, said the CTG had been misinterpreted and, had it been read properly, the drug would not have been administered and the foetus would have been assessed.
She also criticised Dr Madu, saying a locum doctor would not have known the abilities of the midwives.
Record-keeping was also found to be incomplete.
Ms Johnston said recordkeeping was necessary for staff and added that midwives should raise the issue with the hospital trust, who could employ extra staff.
The inquest continues.