Bedford Hospital [HSI NHS Trust Response by Bedford Hospital to HM Senior Coroner's Regulation 28 Report dated 21 April 2015 The report drew attention to three matters of concern_ These are listed below, together with the Trust's response to each That a newly qualified Midwife was allocated to deliver a baby when_during the course_of_her_training and her practice since qualifying_she_had never assisted with the_ resuscitation of a new born baby_TheMidwife_had no further support A newly qualified midwife enters onto the Nursing and Midwifery Register once the required standard in all aspects of training are met This assessment is carried out by the training University: At the point of registration a midwife is deemed competent in all aspects of midwifery care including resuscitation of the new born. The Nursing and Midwifery Council Standards for pre-registration Midwifery Education states that upon entering the professional register, midwives are expected to "examine and care for the new born infant: to take all initiatives which are necessary in cases of need and to carry out where necessary immediate resuscitation" (NMC , 2009). There are many clinical scenarios that midwives are taught to manage during training that may or may not encounter during the course of their work. It is usual that within modern pre- registration training and registration practise, practitioner acquires the necessary clinical skills and knowledge by the means of simulation scenario- based training_ This is a robust method of training within pre-registration midwifery programmes generally, with competence formally assessed and evidenced_ The incidence of term babies requiring extensive resuscitation is rare.Therefore the majority of midwives are highly unlikely to experience this actual situation and some may not do so throughout the course of their professional career: Neonatal resuscitation through assimilation assessment forms one part of the interview and selection process for recruiting all midwives to the maternity unit at Bedford Hospital All midwives subsequently employed within the Maternity Unit are required to attend mandatory annual training in resuscitation, to ensure that their knowledge and skills are up to date. This includes a refresher of theory and simulation (practical) training using mannequins and resuscitation equipment; under the expert supervision of accredited PROMPT (PRactical Obstetric Multi-Professional Training) trainers_ This session is delivered through a well-established rolling programme The Trust recognises that all new members of staff, whatever their experience, need a period of time to become familiar with local procedures and practices Within the Maternity Unit at Bedford Hospital, an orientation period is allocated_ 'New starters' unfamiliar with the Trust (including a newly qualified midwife) would undertake this programme for up to a month: Within this period, the new starter works with a nominated midwife for support and is expected to complete a bespoke orientation programme, developed following discussion

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Bedford Hospital [HSI NHS Trust with colleaguesl their supervisor of midwives, designed to meet their individual learning needs_ 'new starter' midwife has support from a number of sources that include a named 'Preceptor Midwife' a named Midwifery Team Manager and a named Supervisor of Midwives_ The midwife receives guidance in reflecting on their practise and feedback on their performance colleagues at all levels, to ensure that they establish a cycle of learning and personal development beyond registration The midwife involved in this case had successfully completed a Neonatal Advance Life Support course towards the end of her pre professional training, in addition to the core resuscitation training within the programme_ The midwife's resuscitation skills were tested at interview as part of the recruitment process and she scored highly. The Nursing and Midwifery Council (NMC 2008, NMC 2012) state that 'a midwife must seek assistance should she require help. This would be at any time during labour; delivery of the baby and postnatal period. It is the responsibility of the midwife to summon assistance as the clinical situation warrants_ The midwife concerned worked as part of the Labour Ward team on duty that shift and had access to the senior midwife in charge and the medical team for support. Each delivery room has an emergency bell to summon help Since this very sad event the midwife has attended a further Neonatal Life Support (NLS) course and has been subsequently asked to become a trainer by the Resuscitation Council (GB): The Trust considers therefore that the systems and processes that it had and still does have in place in relation to this concern meet national requirements. Practices are in line with practices in other maternity units_ This minimises the risk from lack of 'hands on' practical experience and ensures that staff have the required skills and support when needed: That the allocation of_women to midwives on a shift by shift basis did not_and does not_take_into account the_experience_of the_individual midwife There is a senior midwife in charge of each shift in Delivery Suite, often without a case load of their own. Helshe risk assesses the complexity of the case mix of womenlpatients at every handover; using the SBAR (Situation, Background; Assessment; Recommendation) tool and allocates the care of women accordingly, taking into account staff experience, competencies and confidence_ The position is continually assessed throughout the shift; taking into account such factors as admissions to the Delivery Suite, clinical complications developing during delivery, the increasing complexity of workload and the available capacity within the unit. Reviews are recorded hourly proforma developed by the former National Patient Safety Agency (NPSA) copy attached The Trust's Senior Midwife in Charge Policy (copy attached) state that the role is to:

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Bedford Hospital NHS] NHS Trust allocate women on the Delivery Suite to the care of specific midwives according to the skill mix and complexity of the woman's needs Helshe will be aware of any development needs: The Senior Midwife in Charge should establish any support the midwife may need for that allocation of work and ensure this is in place. Each midwife has a responsibility to inform the Midwife in Charge if helshe feels unable to provide care competently and confidently and within their knowledge base_ The Nursing and Midwifery Council does not stipulate that a midwife must have a second person in attendance at the time of the birth: When the Trust's Head of Midwifery raised this issue at a meeting of the Contact Supervisor of Midwives' meeting in April 2015, it was confirmed that this approach is replicated in maternity units across the East Midlands and East of England region. In line with the Code of Conduct and Iocal Trust policy, it is the responsibility of the midwife to request support if helshe requires it_ Baby Willow's mother was classified as a 'low risk' case throughout her pregnancy and this classification was not changed on her admission to the Delivery Suite or throughout labour: The hospital Clinical Guideline for 'Care of women in labour in all care settings' copy attached) fully describes the Care of Healthy Women and Babies in Normal Labour (Section
2). Sadly, Baby Willow deteriorated following her birth and died. The Trust is satisfied that the allocation of the new graduate midwife to this 'Iow risk' case was, as considered both at the time and on reflection post this event; to be an appropriate decision The Trust considers therefore that the systems and processes it had and still does have in place in relation to this concern minimise the risk of inappropriate allocation of staff: 3_ The system of 'Supervisors of_Midwives' _ as it operates at Bedford Hospital_isin urgent need of review toensure_that it is_working _to_support pregnant womenand midwives wthin the_Trust The statutory Supervision of Midwifery system in the Trust is modelled on the recommendations in the Local Supervising Authority Standards for Supervision (2009). An annual Supervision of Midwifery (SoM) Report is received by the Trust Board and Local Supervising Authority for Midwifery and this demonstrates full compliance. A SoM Information Leaflet_ based on the NMC leaflet "Support for Parents How supervision and supervisors of midwives can help you (2009) is given to pregnant woman when she registers her pregnancy through a process called 'booking' This leaflet sign-posts the family on how to access a Supervisor of Midwives and outlines the functions of statutory supervision. Bedford Hospital SoMs have an 'on call' rota, covering 24 hours availability, 365 days a year and may be contacted by both users of the service and staff working both locally and regionally, for advice and support_ The family in this tragic case had the involvement of a SoM during and after the completion of the investigation and prior to, during and since the Coroner's Inquest Hearing: A Local Supervising Authority (LSA) SoM Investigation was undertaken and an abridged version of the report was made available to the family and the Coroner by the LSA

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Bedford Hospital NHS NHS Trust The LSA Midwifery Officer, NHS England (Midlands and East) , is clear that the Trust is compliant with Statutory Supervision and would raise any concerns that she had directly with the Chief Executive Officer or Director of Nursing: To date , no issues have been raised and she would be happy to discuss any further concerns regarding the SoM report concerning this case or indeed statutory Supervision of Midwives generally_ Her contact details are: - Local Supervising Authority Midwifery Officer Telephone: The Trust and the LSA officer therefore consider that the system of statutory Supervision of Midwives operating at Bedford Hospital is working effectively to provide support to both mothers and midwives: Stephen Conroy Chief Executive June 2015