Midwife made 'basic' errors in baby's care - panel

A midwife involved in the care of a mother whose baby died 27 minutes after she was born has been given a 12-month suspension order.

Fiona Winser-Ramm and Dan Ramm's daughter, Aliona, died at Leeds General Infirmary (LGI) on 1 January 2020.

An inquest in 2023 concluded there were "a number of gross failures of the most basic nature that directly contributed to Aliona's death", with a coroner finding there was "neglect" in her care from midwives.

A fitness to practise hearing held by the The Nursing and Midwifery Council (NMC) this week concluded midwife Yvette Veronica Lake's actions fell "significantly short of standards expected".

Lake, who has since retired from midwifery, was found to have failed to recognise or categorise that Aliona's cardiotocograph scan - which records the baby's heart rate and the mother's uterine contractions - was abnormal and failed to request a review from the obstetric team on three separate occasions during labour.

She also failed to electronically document her interactions with Aliona's parents, the panel said.

"These errors go against basic and fundamental matters of patient care," the NMC said in its submissions.

At the time, Lake had been a senior midwife acting as labour ward coordinator at the LGI, having been registered in the profession since 1990.

Gemma McIntyre, a midwifery expert who gave evidence to the hearing, said Lake created an "unwarranted risk of harm" for Aliona and her mother through her misconduct.

The panel said there were no mitigating factors in the case and "limited evidence of remediation, remorse and insight" from Lake, who chose not to attend the hearing.

In a previous statement, issued in 2022, Lake said: "On reflection and on reviewing the notes, I can see there were some instances where the care I provided could have been better, and for that I am truly sorry."

The panel concluded a striking-off order for Lake would be "unduly punitive" because the errors made were "potentially capable of remediation".

Responding to the hearing's conclusion, Fiona Winser-Ramm and Dan Ramm said in a statement: "Whilst today brings a small sense of accountability and consequence, we believe the NMC decision did not yet go far enough for a healthy child who died due to neglect.

"This suspension order is the first action resembling any individual accountability in the nearly seven years since our daughter's death.

"During that time, we have had to carry the heavy burden of fighting for the bare minimum of truth and consequences, while the institutions around us remained silent."

Following the hearing, Beverley Geary, chief nurse at Leeds Teaching Hospitals NHS Trust, said: "Our thoughts are with Aliona's family, and we continue to extend our deepest apologies and condolences to Fiona and Dan for the profound loss they have experienced.

"We recognise the lasting impact this has had on them and their loved ones."

A fitness to practise hearing which began earlier this year for two of Lake's former colleagues over their care for Aliona and her mother has been adjourned until 2027.

An independent inquiry into failings in maternity and neonatal services at Leeds Teaching Hospitals NHS Trust is due to begin in November and is expected to conclude by 2029.

It comes after a BBC investigation revealed that the deaths of at least 56 babies and two mothers at Leeds Teaching Hospitals Health Trust over the past five years may have been prevented.

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