When analysing the reviews, there was a recurring theme of perceived inadequate staffinglevels and high unit activity contributing towards staff stress and fatigue.
In some instances, it was understandable how the external stressors contributed to the baby’s injury:
“The unit was experiencing high levels of clinical activity. A statement from the shift labour ward coordinator indicates all delivery rooms and recovery beds were occupied with simultaneous emergencies occurring. At the time of the second fetal bradycardia the ST7 was in labour ward theatre preparing a woman for a potentially complicated category 2 caesarean section.”
There were also instances where fatigue was clearly a contributory factor:
The midwife concerned had been working for a long period of time, having worked in the community during the day, and after a short break was called in to the birth centre for support. She had recognised that she was now tired and planned to go home. Her tiredness led to her losing sight of the situation when dealing with the telephone call from the mother.
According to the midwife’s statement, tiredness led to her failing to detail elements of her conversation in the telephone record, leading to key information being missed. A woman was sent inappropriately to a midwife-led unit.
This was echoed in another very similar situation:
“The midwife reported that she did not have a break during a very busy night shift and identified that she was very tired and thought this might be the reason she did not complete the telephone message.”
Whilst the arguments for too-busy labour wards or midwifery-led units were cogent or logical, some did not seem plausibly connected. In one report, the following connection between high workload and clinical outcome was made:
“Unexpectedly high workload [led to] failure to recognise delay in 2nd stage.”
In this instance, a midwifery student was looking after a multiparous woman who was fully dilated on admission and then remained in the second stage for a further 3.5 hours. The medical team then administered oxytocin. It was not clear what the high workload was in this case, but it was concerning that such a long second stage was accepted, by different health professionals. It seems unlikely that this would be solely attributable to a high workload, but no further factors were identified by the local team undertaking the review of this woman’s care.