Advising with empathy and experience

Baby died after monitor alarm was switched off


A baby boy died after a midwife switched off a heart monitor alarm warning that his life was in danger 16 times during his birth in an example of what experts warn is a ‘commonplace’ inability of midwives to use life-saving machines competently.

Rupert Sanders was choked in the womb when the placental cord caught around his neck depriving him of oxygenated blood.

Instead of picking up on warnings from the bedside cardiotocograph (CTG) machine that Rupert was struggling and calling an obstetrician for help, the midwife on duty repeatedly cancelled the machine’s alarm in the mistaken belief there was nothing wrong. A fellow midwife also failed to recognise what was happening.

Rupert Sanders, who was born in Stafford hospital in 2012, died three days later.

First-time mother Lauren, then 27, was admitted to the labour ward at Stafford hospital at 2.25pm on December 23, 2012, after her waters broke the previous day.

Everything was progressing normally, but at 10.30pm the main midwife neglected to check the CTG machine, as she was meant to do. Fifteen minutes later, Rupert’s heartbeat dipped – the first sign of trouble.

At 11.30pm the midwife checked the machine’s paper ‘trace’, classifying it as ‘suspicious’ an analysis confirmed by her colleague. At that moment they should have called a doctor, as protocols dictate but neither did.

Experts later said their analysis was wrong – Rupert’s heart reading was actually ‘pathological’ from 10.45pm, meaning he was at risk of permanent injury or death for more than two hours until his birth at 1.06am on Christmas Eve.

National Midwifery Council (NMC) documents state: “The alarm on the CTG sounded nine times in the last 30 minutes before the birth, yet this itself did not seem to alert either midwife to the need to inform a doctor. The alarm was cancelled each time.”

Mrs Sanders said: “The alarm sounded 16 times but it was silenced and no doctor was called. I will forever bear so much guilt that I did nothing to stop this from happening.”

An obstetrician told the NMC that if a timely caesarean had been carried out – at around 11.40pm – then Rupert “would have survived.”

Mrs Sanders mother, who was at the birth, recalled: “I am convinced that both midwives were utterly unaware of what was happening. They didn’t give any cause for concern, or Lauren would have jumped on it. She put her trust in the hands of fellow professionals but they failed.”

In the following weeks, Lauren and Rob assumed something catastrophic but unavoidable had happened in labour but 15 months later, following the birth of a daughter by caesarean, Lauren Sanders asked Stafford Hospital for Rupert’s birthing notes.

Besides the errors themselves, she learnt the hospital had carried out an internal Serious Incident Review, which was passed to the senior midwife, a local midwifery ‘supervisor’ who knew one of the midwives well and did not refer the matter to the NMC. She only recommended that both women underwent remedial training. 

After learning of the internal reviews, Lauren Sanders referred both her midwives to the NMC. One was given a five-year caution while the other received an 18-month interim suspension.

The failings in the case of Rupert Sanders form part of wider concerns. In February 2017, coroner, Mr Hinchcliff, wrote to the heads of the Royal College of Midwives and Royal College of Obstetricians and Gynaecologists about the death of another baby, Maxim. 

In that letter and in another, sent weeks later in relation to the death of a third baby, Billy Wilson, he recommended mandatory ‘pass or fail testing’ for use of CTG machines by midwives and doctors before they could be allowed to work on labour wards.

In a written submission to Billy’s inquest, Mr Hinchcliff quoted a midwifery expert who had said that it was “commonplace that student midwives can qualify and become registered without this essential training.”

An obstetrician and expert witness, Prof Philip Steer, said there was “no formal assessment of competence” in CTG interpretation in most NHS hospitals, and on-the-job training was the norm.

He said that CTG training courses tended to be supported by charities such as Baby Lifeline, and added: “In my opinion, the problem needs to be tackled in a much more systematic way.”

Director of midwifery at the Royal College of Midwives, Louise Silverton, said interpreting CTG traces was “not an exact science.”

Mid Staffordshire NHS Foundation Trust, the organisation responsible in 2012, has been disbanded.

An NMC spokesman said: “The old system of midwifery supervision was not adequate for public protection. The risk of a midwife being investigated at a local level by individuals known to them has now been removed.”

Kim Daniells of the CNCI team commented, "It is tragic that the very warnings that CTG traces provide were ignored and overridden by the midwives who were present at Rupert's delivery. It is shocking that the family should only learn of the hospital failings 15 months later - and as a result of their own enquiries. CTG misinterpretation remains a feature of many birth related injuries that are referred to the CNCI team. Training and assessment of midwives is essential if we are to prevent a recurrence of these terrible events, and if we are to make births safer for mums and babies."