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Conduct and Competence Committee Substantive Hearing
Date: 27 April to 20 May 2015 The Nursing and Midwifery Council, 2 Stratford Place, Stratford, London
Name of Registrant Midwife: Mrs Marie Teresa Ratcliffe NMC PIN: 79A2836E Part(s) of the register: Registered Nurse and Midwife – Sub Part 1 Adult Nurse (June 1982) Midwifery (November 1990) Area of Registered Address: England
Type of Case: Misconduct
Panel Members: Gary Leong (Chair / Lay)
Janet Blundell (Lay member)
Jeffrey Heath (Registrant member)
Legal Assessor: Nigel Pascoe QC
Panel Secretary: Tom Stone
Representation: Not present nor represented
Nursing and Midwifery Council: Represented by Amanda Hamilton, counsel,
instructed by, NMC Regulatory Legal Team
Facts proved: 1.1, 1.2, 1.3, 1.4 (i), 2.1 (i and ii), 2.2, 2.3 (i, ii,
iii, iv), 2.4 (i, ii, iii and iv), 2.5, 2.6 (i), 3.1, 3.2, 3.3, 3.4, 4.1 (i and ii), 4.2, 5.1, 5.2, 5.3, 5.4, 5.5, 6.1, 6.2, 6.3, 6.4, 6.5, 6.6, 7.1, 7.2, 7.4, 8.1, 8.2, 8.3, 8.4, 8.5, 8.6 (i), 8.7, 9.1, 9.2, 9.4, 10.2, 10.3, 11.4, 12.1, 12.2, 13.1, 13.3, 13.4, 13.5, 14.1, 14.2, 14.3 (i, ii and iii) and 14.4
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Facts not proved: 1.4 (ii), 2.6 (ii), 3.5, 7.3, 7.5, 8.6 (ii), 8.8 9.3, 10.1,
11.1, 11.2, 11.3, 12.3, 12.4 and 13.2 Fitness to Practise: Impaired
Sanction: Striking off Order Interim order: Interim Suspension Order, 18 months Decision on Service of Notice of Hearing: The panel was informed at the start of this hearing that Mrs Ratcliffe was not in
attendance.
In the light of the information available, the panel was satisfied that notice had been
served, as advised by the legal assessor, in compliance and accordance with Rules 11
and 34 of The Nursing and Midwifery Council (Fitness to Practise) Rules Order of Council
2004 (as amended February 2012) (The Rules).
11.— (2) The notice of hearing shall be sent to the registrant—
(b) in every case, no later than 28 days before the date fixed for the hearing.
34.—(1) Any notice of hearing required to be served upon the registrant shall be delivered
by sending it by a postal service or other delivery service in which delivery or receipt is
recorded to,
(a) her address in the register
Notice of this hearing was sent to Mrs Ratcliffe on 17 March 2015 by recorded delivery to
her address on the register which complies with the rules of service.
Proceeding in the absence The panel then considered continuing in the absence of Mrs Ratcliffe. The panel heard
the submissions made by Ms Hamilton on behalf of the Nursing and Midwifery Council
(NMC) and took account of the legal assessor’s advice.
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The panel was mindful that this was a discretion that must be handled with the utmost care
and caution.
In deciding whether to proceed in the absence of Mrs Ratcliffe, the panel weighed its
responsibilities for public protection and the expeditious disposal of the case with Mrs
Ratcliffe’s right to a fair hearing.
The panel noted the correspondence from Mrs Ratcliffe, dated 24 March 2015 in which
she stated:
‘I have chosen not to defend myself against any of the charges brought against me
at this hearing. I will not be in attendance or be represented.’
Mrs Ratcliffe had been sent notice of today’s hearing and the panel was therefore satisfied
that she was or should be aware of today’s hearing and it was of the view that she has
chosen to disengage. Therefore, the panel concluded that she had chosen voluntarily to
absent herself. The panel had no reason to believe that an adjournment would result in
Mrs Ratcliffe attendance. Having weighed the interests of Mrs Ratcliffe with those of the
NMC and the public interest in an expeditious disposal of this hearing the panel has
determined to proceed in Mrs Ratcliffe’s absence.
Details of charge:
That you, whilst employed as a Band 7 Midwife at Furness General Hospital (“the Hospital”) by University Hospitals of Morecambe Bay NHS Foundation Trust (“the Trust”) between 15 February 2004 and 10 September 2013: 1. On 25 February 2004 an in relation to Patient A
1.1 Failed to and/or failed to ensure that the fetal heart rate was adequately monitored
after 20:15 and up until the time that Patient A’s baby was delivered
1.2 Failed to request assistance from a Doctor and/or any other suitably qualified medical professional when you had difficulty auscultating the fetal heart.
1.3 Caused distress to Patient A by inappropriately placing Patient A’s baby by her side
1.4 Your conduct contributed to the death of Patient A’s baby and/or caused Patient A’s baby to lose a significant chance of survival.
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2. On 6 September 2008 in relation to Patient B
2.1 In relation to Patient B’s pain relief; i) Advised Patient B that she could not have an epidural ii) Failed to document your discussions with Patient B regarding pain
2.2 Failed to and/or failed to ensure that the fetal heart rate was monitored at 15-30 minute intervals during the first stage of labour;
2.3 Failed to observe and/or record the following: iii) The maternal temperature at four hourly intervals iv) Maternal blood pressure at four hour intervals in the first stage of labour v) Maternal blood pressure at hourly intervals in the second stage of labour vi) Maternal pulse at hourly intervals
2.4 After approximately 21.25 when you had resumed the care of Patient B you failed
to adequately monitor and/or ensure that the fetal heart rate was being adequately monitored in that you:
i) Failed to and/or failed to ensure that continuous electronic fetal monitoring was in place and/or
ii) Failed to and/or failed to ensure that the fetal heart rate was auscultated every 5 minutes and/or
iii) Failed to and/or failed to ensure that the fetal heart rate was auscultated
after every contraction for one minute and/or
iv) Failed to and/or failed to ensure that a fetal scalp electrode was used to monitor the fetal heart rate
2.5 Failed to adequately escalate the delay in the second stage of labour to an
obstetrician at approximately 20:45
2.6 Your conduct contributed to the death of Patient B’s baby and/or caused Patient B’s baby to lose a significant chance of survival
3. On 11 and/or 12 June 2009 when delivering intrapartum care to Patient D: 3.1 Did not monitor and/or record the temperature of the birthing pool as required; 3.2 Did not document the reason why you artificially ruptured Patient
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D’s membranes; 3.3 Did not monitor and/or record the maternal observations; 3.4 Did not ensure that Patient D’s urine was tested and/or record that you had tested Patient D’s urine or 3.5 In the alternative to charge 3.4 above failed to record the reason for not testing Patient D’s urine
4. On 9 February 2009, when delivering intrapartum care to Patient E: 4.1 Did not monitor and/or record maternal observations
i) During the birth and/or ii) After the birth
4.2 Did not document any records on the partogram
5. On 17 February 2009, when delivering intrapartum care to Patient F: 5.1 Did not adequately document the reason why you artificially ruptured Patient F’s membranes; 5.2 Did not document any records on the partogram after you took over the care of Patient F 5.3 Did not monitor and/or record maternal observations during labour; 5.4 Did not monitor and/or record maternal postnatal observations 5.5 Failed to seek the advice of the Registrar after Patient F after 1 hour of Patient F having been in the active second stage of labour
6. On 20 February 2009, when delivering intrapartum care to Patient G: 6.1 Did not record any records on the partogram 6.2 Failed to request suitable medical assistance when you encountered a cord prolapse; 6.3 Did not monitor and/or document the fetal heart rate between the
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cord prolapse and the baby’s delivery; 6.4 Did not fully assess and/or record a full description of the CTG in the maternal notes 6.5 Did not record the rationale for using the “wood screw” manoeuvre 6.6 Did not seek assistance from the medical team when you realised that Patient G’s head was caught by the umbilical cord and/or did not document that you had sought assistance
7. On an unknown date when delivering intrapartum care to Patient H: 7.1 Did not document the rationale for performing an artificial rupture of Patient H’s membranes 7.2 Did not document any records on the partogram; 7.3 Did not monitor and/or record the fetal heart rate 7.4 Did not document the maternal observations 7.5 Did not document that Patient H was given facial oxygen and/or that her position had been changed
8. On 5 March 2009 when delivering intrapartum care to Patient I; 8.1 Did not monitor Patient I in labour using a CTG as required; 8.2 Did not take Patient I’s bloods for “group and save” 8.3 Did not insert a venflon 8.4 Did not conduct and/or record maternal observations in labour 8.5 Did not conduct and/or record maternal postnatal observations 8.6 When you encountered a shoulder dystocia:
i) Failed to request medical assistance; or in the alternative ii) Did not record that you requested medical assistance and/or the outcome of
the request. 8.7 Did not record that Patient I had previously had heart surgery 8.8 Did not consider and/or record that you had considered that intrapartum antibiotics may be required
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9. On 23 February 2009, when delivering intrapartum care to Patient J;
9.1 Did not record the fetal heart rate in the text section of the maternal notes; 9.2 Did not conduct and/or record abdominal palpations 9.3 Did not record a description of the liquor after Patient J’s membranes were ruptured 9.4 Did not ensure that the administration of syntometrine in third stage labour was recorded in the electronic notes
10. On 27 February 2009, when delivering intrapartum care to Patient K;
10.1 Failed to monitor and/or record Patient K’s blood pressure during labour; 10.2 Failed to monitor and/or record Patient K’s blood pressure after she delivered her baby. 10.3 Did not document the dosage of syntocinon that was administered to Patient K during labour
11. On 15 July 2009, when delivering intrapartum care to Patient L:
11.1 Did not provide a clear interpretation of the CTG in the Patient notes and /or
11.2 Failed to undertake an effective assessment of the CTG 11.3 Did not monitor and/or record the maternal pulse at the start of the
CTG; 11.4 Did not effectively monitor the fetal heart rate during the second stage of labour and/or failed to record the fetal rate on the partogram during the second stage of labour
12. On 4 April 2009, when delivering intrapartum care to Patient M:
12.1 Did not document the rationale for the artificial rupture of membranes; 12.2 Did not conduct and/or record maternal observations after you took over the care of the Patient M between 7:45 and 10.30;
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12.3 Did not record the fetal heart rate on the text section of the notes; 12.4 Did not record that Syntometrine had been administered in the third stage of labour
13. On 12/13 August 2009, when delivering intrapartum care to Patient N: 13.1 Did not conduct and/or adequately record maternal observations; 13.2 Did not record the fetal heart rate on the partogram 13.3 Did not document a detailed description of the CTG trace in the notes 13.4 Did not record the dosage of syntocinon that was administered to Patient N; 13.5 Did not record the dosage of ergometrine that was administered to Patient N
14. On 9/10 September 2013, when conducting a shift as Labour Ward
Coordinator and in relation to Patient O; 14.1 Failed to check on Colleague A and/or Patient O between approximately 22.15 and 03.20; 14.2 Failed to request medical assistance when you became aware that the fetal heart rate was bradycardia; 14.3 Failed to makes accurate “fresh eyes” observation at around 22.15 in that you;
i) Documented that Patient O’s Labour was spontaneous when Patient O’s labour was in fact induced;
ii) Documented that there was no deceleration on the CTG when the CTG showed decelerations;
iii) Categorised the CTG as normal when it was in fact suspicious
14.4 Failed to make any records in the “delivered by” section of Patient O’s notes despite having delivered the baby
AND in light of the above, your fitness to practise is impaired by reason of your misconduct.
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Decision and reasons on application to amend charge: The panel heard an application made by Ms Hamilton, on behalf of the NMC, to amend the
wording of charge 2.3 and 5.5.
The proposed amendment was to correct a typographical mistake. It was submitted by Ms
Hamilton that the proposed amendment would not cause any injustice to Mrs Ratcliffe as
the amendments did not make a substantive change to meaning of the charges.
Charge 2.3 would be amended to read:
i) The maternal temperature at four hourly intervals ii) Maternal blood pressure at four hour intervals in the first stage of labour iii) Maternal blood pressure at hourly intervals in the second stage of labour iv) Maternal pulse at hourly intervals
Charge 5.5 would be amended to read:
5.5 Failed to seek the advice of the Registrar for Patient F after 1 hour of Patient F having been in the active second stage of labour
The panel sought submissions from Ms Hamilton on amendments to charges 1, 6.6, 11.4,
14.2 and 14.3. Ms Hamilton submitted that the proposed amendments to those charges
were typographical amendments and did not alter the substantive meaning of the charges.
She submitted that such amendments would not prejudice Mrs Ratcliffe.
The stem of charge 1 be amended to read:
1.On 25 February 2004 and in relation to Patient A
Charge 6.6 would be amended to read:
6.6 Did not seek assistance from the medical team when you realised that the
baby’s head was caught by the umbilical cord and/or did not document that you
had sought assistance
Charge 11.4 would be amended to read:
11.4 Did not effectively monitor the fetal heart rate during the second stage of
labour and/or failed to record the fetal heart rate on the partogram during the
second stage of labour
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Charge 14.2 would be amended to read:
14.2 Failed to request medical assistance when you became aware that the fetal heart rate was bradycardic;
Charge 14.3 would be amended to read:
14.3 Failed to make accurate “fresh eyes” observation at around 22.15 in that you;
The panel accepted the advice of the legal assessor that Rule 28 of The Nursing and
Midwifery Council (Fitness to Practise) Rules Order of Council 2004 (as amended 2012)
(The Rules) states:
28.—(1) At any stage before making its findings of fact…
(i)… the Conduct and Competence Committee, may amend—
(a) the charge set out in the notice of hearing…
unless, having regard to the merits of the case and the fairness of the proceedings, the
required amendment cannot be made without injustice.
The panel was of the view that such an amendment as applied for was in the interest of
justice. The panel was satisfied that there would be no prejudice to Mrs Ratcliffe and no
injustice would be caused to either party by the proposed amendment being allowed. It
was therefore appropriate to allow the amendment as applied for to ensure clarity,
accuracy and simplicity.
Decision and reasons on a further application to amend the charge sheet: The panel heard an application made by Ms Hamilton, on behalf of the NMC, to amend the
wording of charge 1.1, 1.4 2.2, 2.3, 2.4 and 2.6.
The proposed amendment was to provide greater clarity and narrow the meaning of the
charges. It was submitted by Ms Hamilton that the proposed amendment would not cause
any injustice to Mrs Ratcliffe as the amendments did not make a substantive change to
meaning of the charges nor does the proposed amendments widen the meaning of the
charges.
The panel was of the view that such an amendment as applied for was in the interest of
justice. The panel was satisfied that there would be no prejudice to Mrs Ratcliffe and no
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injustice would be caused to either party by the proposed amendment being allowed. It
was therefore appropriate to allow the amendment as applied for to ensure clarity,
accuracy and simplicity.
For the avoidance of doubt, the full set of amended charges is listed below.
Details of charge, as amended
That you, whilst employed as a Band 7 Midwife at Furness General Hospital (“the Hospital”) by University Hospitals of Morecambe Bay NHS Foundation Trust (“the Trust”) between 15 February 2004 and 10 September 2013: 1. On 25 February 2004 and in relation to Patient A
1.5 Failed to adequately monitor the fetal heart rate after 20:15 and up until the time
that Patient A’s baby was delivered
1.6 Failed to request assistance from a Doctor and/or any other suitably qualified medical professional when you had difficulty auscultating the fetal heart.
1.7 Caused distress to Patient A by inappropriately placing Patient A’s baby by her side
1.8 Your conduct: i) contributed to the death of Patient A’s baby and/or; ii) caused Patient A’s baby to lose a significant chance of survival.
2. On 6 September 2008 in relation to Patient B
2.7 In relation to Patient B’s pain relief; i) Advised Patient B that she could not have an epidural ii) Failed to document your discussions with Patient B regarding pain
2.8 Failed to monitor the fetal heart rate at 15-30 minute intervals during the first stage of labour;
2.9 Failed to observe and/or record the following:
i) The maternal temperature at four hourly intervals ii) Maternal blood pressure at four hour intervals in the first stage of labour iii) Maternal blood pressure at hourly intervals in the second stage of labour iv) Maternal pulse at hourly intervals
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2.10 After approximately 21.25 when you had resumed the care of Patient B you failed to adequately monitor and/or ensure that the fetal heart rate was being adequately monitored in that you:
v) Failed to maintain continuous electronic fetal monitoring and/or
vi) Failed to auscultate that the fetal heart rate every 5 minutes and/or
vii) Failed to auscultate the fetal heart rate after every contraction for one minute and/or
viii) Failed to apply a fetal scalp electrode to monitor the fetal heart rate
2.11 Failed to adequately escalate the delay in the second stage of labour to an
obstetrician at approximately 20:45
2.12 Your conduct: i) contributed to the death of Patient B’s baby and/or; ii) caused Patient B’s baby to lose a significant chance of survival
3. On 11 and/or 12 June 2009 when delivering intrapartum care to Patient D: 3.1 Did not monitor and/or record the temperature of the birthing pool as required; 3.2 Did not document the reason why you artificially ruptured Patient D’s membranes; 3.3 Did not monitor and/or record the maternal observations; 3.4 Did not ensure that Patient D’s urine was tested and/or record that you had tested Patient D’s urine or 3.5 In the alternative to charge 3.4 above failed to record the reason for not testing Patient D’s urine
4. On 9 February 2009, when delivering intrapartum care to Patient E: 4.1 Did not monitor and/or record maternal observations
i) During the birth and/or ii) After the birth
4.2 Did not document any records on the partogram
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5. On 17 February 2009, when delivering intrapartum care to Patient F: 5.1 Did not adequately document the reason why you artificially ruptured Patient F’s membranes; 5.2 Did not document any records on the partogram after you took over the care of Patient F 5.3 Did not monitor and/or record maternal observations during labour; 5.4 Did not monitor and/or record maternal postnatal observations 5.5 Failed to seek the advice of the Registrar for Patient F after 1 hour of Patient F having been in the active second stage of labour
6. On 20 February 2009, when delivering intrapartum care to Patient G: 6.1 Did not record any records on the partogram 6.2 Failed to request suitable medical assistance when you encountered a cord prolapse; 6.3 Did not monitor and/or document the fetal heart rate between the cord prolapse and the baby’s delivery; 6.4 Did not fully assess and/or record a full description of the CTG in the maternal notes 6.5 Did not record the rationale for using the “wood screw” manoeuvre 6.6 Did not seek assistance from the medical team when you realised that the baby’s head was caught by the umbilical cord and/or did not document that you had sought assistance
7. On 22nd June 2009 when delivering intrapartum care to Patient H: 7.1 Did not document the rationale for performing an artificial rupture of Patient H’s membranes 7.2 Did not document any records on the partogram; 7.3 Did not monitor and/or record the fetal heart rate
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7.4 Did not document the maternal observations 7.5 Did not document that Patient H was given facial oxygen and/or that her position had been changed
8. On 5 March 2009 when delivering intrapartum care to Patient I; 8.1 Did not monitor Patient I in labour using a CTG as required; 8.2 Did not take Patient I’s bloods for “group and save” 8.3 Did not insert a venflon 8.4 Did not conduct and/or record maternal observations in labour 8.5 Did not conduct and/or record maternal postnatal observations 8.6 When you encountered a shoulder dystocia:
i) Failed to request medical assistance; or in the alternative ii) Did not record that you requested medical assistance and/or the outcome of
the request. 8.7 Did not record that Patient I had previously had heart surgery 8.8 Did not consider and/or record that you had considered that intrapartum antibiotics may be required
9. On 23 February 2009, when delivering intrapartum care to Patient J;
9.1 Did not record the fetal heart rate in the text section of the maternal notes; 9.2 Did not conduct and/or record abdominal palpations 9.3 Did not record a description of the liquor after Patient J’s membranes were ruptured 9.4 Did not ensure that the administration of syntometrine in third stage labour was recorded in the electronic notes
10. On 27 February 2009, when delivering intrapartum care to Patient K;
10.1 Failed to monitor and/or record Patient K’s blood pressure during labour;
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10.2 Failed to monitor and/or record Patient K’s blood pressure after she delivered her baby. 10.3 Did not document the dosage of syntocinon that was administered to Patient K during labour
11. On 15 July 2009, when delivering intrapartum care to Patient L:
11.1 Did not provide a clear interpretation of the CTG in the Patient notes and /or
11.2 Failed to undertake an effective assessment of the CTG 11.3 Did not monitor and/or record the maternal pulse at the start of the
CTG; 11.4 Did not effectively monitor the fetal heart rate during the second stage of labour and/or failed to record the fetal heart rate on the partogram during the second stage of labour
12. On 4 April 2009, when delivering intrapartum care to Patient M:
12.1 Did not document the rationale for the artificial rupture of membranes; 12.2 Did not conduct and/or record maternal observations after you took over the care of the Patient M between 7:45 and 10.30; 12.3 Did not record the fetal heart rate on the text section of the notes; 12.4 Did not record that Syntometrine had been administered in the third stage of labour
13. On 12/13 August 2009, when delivering intrapartum care to Patient N: 13.1 Did not conduct and/or adequately record maternal observations; 13.2 Did not record the fetal heart rate on the partogram 13.3 Did not document a detailed description of the CTG trace in the notes 13.4 Did not record the dosage of syntocinon that was administered to Patient N; 13.5 Did not record the dosage of ergometrine that was administered to
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Patient N
14. On 9/10 September 2013, when conducting a shift as Labour Ward Coordinator and in relation to Patient O; 14.1 Failed to check on Colleague A and/or Patient O between approximately 22.15 and 03.20; 14.2 Failed to request medical assistance when you became aware that the fetal heart rate was bradycardiac; 14.3 Failed to make accurate “fresh eyes” observation at around 22.15 in that you;
i) Documented that Patient O’s Labour was spontaneous when Patient O’s labour was in fact induced;
ii) Documented that there was no deceleration on the CTG when the CTG showed decelerations;
iii) Categorised the CTG as normal when it was in fact suspicious
14.4 Failed to make any records in the “delivered by” section of Patient O’s notes despite having delivered the baby
AND in light of the above, your fitness to practise is impaired by reason of your misconduct.
Background Mrs Ratcliffe qualified as a nurse in 1982 and completed her midwifery training at the
Royal Lancaster Infirmary in 1990. She took up the position of a Grade E Midwife at the
Furness General Hospital (‘the Hospital’) in November 1990. On 6th April 1997, Mrs
Ratcliffe was promoted to Midwifery Sister, a position that became known as a Band 7
Coordinator post and she remained in employment at that grade with the University
Hospitals of Morecambe Bay NHS Foundation Trust (‘the Trust’) until her resignation in
December 2013.
The Trust referred Mrs Ratcliffe to the NMC on 16th December 2013 following a clinical
incident report relating to the midwifery care delivered by Mrs Ratcliffe to Patient O during
the night shift of 9th to 10th September 2013. Patient O’s baby was born in a poor condition
requiring intubation and admission to the special care baby unit (SCBU). The baby was
later discharged home and is currently well.
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Patient O’s care is the subject of Mrs Ratcliffe’s first referral to the NMC but was made
against a background of internal management reviews and midwifery supervisory
investigations arising from the neonatal death of Patient A’s baby in 2004, the stillbirth of
Patient B’s baby in 2008 and an audit of eleven randomly selected labour ward notes in
2009. The 2009 audit revealed a pattern of failures in record keeping and the midwifery
care provided by Mrs Ratcliffe.
Following the 2013 audit, Ms 12 presented the management’s case at Mrs Ratcliffe’s
disciplinary hearing on 3 February 2014, which took place in the absence of Mrs Ratcliffe,
as she had resigned on 30 December 2013.
The outcome of the disciplinary investigation was that Mrs Ratcliffe would have been
dismissed if she had not already resigned.
At this hearing, Mrs Ratcliffe faces 14 charges involving 83 separate allegations which she
has admitted in the signed Notice of Response dated 24th March 2015.
Morecambe Bay NHS Foundation Trust has faced significant public scrutiny following the
death of Baby A, who was born on 27th October 2008 delivered by Ms 3 assisted by Mrs
Ratcliffe. The mother, Patient C, had had prolonged rupture of membranes and she
received antibiotic treatment. The staff did not recognise that Baby A’s change in
temperature which was a symptom of infection. The baby collapsed on 28th October 2008;
he received treatment in the SCBU but was later transferred to St Mary’s Hospital,
Manchester and then on to the Freeman Hospital, Newcastle where he died on 5th
November 2008. The cause of death was haemorrhage from a necrotic left lung secondary
to pneumococcal infection.
The panel noted that Mrs Ratcliffe is not subject to any charges or criticism over the
management of Baby A as her involvement was confined to the delivery. However, the
coroner decided that an inquest should be held into Baby A’s death. The hearing took
place in June 2011.
The Morecambe Bay Investigation was setup by the Secretary of State for Health in
September 2013 following concerns over serious incidents from January 2004 to June
2013 in the maternity department at Furness General Hospital and the report was
published. The panel has not been provided nor has it seen a copy of the report.
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Decision on the findings on facts and reasons: At the start of the hearing the panel was provided with the Standard Directions Form (‘the
SDF’) which was sent to Mrs Ratcliffe. The panel were informed that the SDF had been
completed, dated 24 March 2015, by Mrs Ratcliffe and returned. In the returned SDF the
panel noted that Mrs Ratcliffe had admitted all the charges against her, including that her
fitness to practise is impaired.
Prior to announcing its findings on the facts, the panel heard oral evidence from:
• Patient A, mother of Baby B;
• Patient B, mother of Baby C;
• Ms 15, Midwife (since 1995), Matron for the maternity and labour wards at the
Trust; and
• Ms 7, Midwife and NMC Expert Witness in relation to charges 1 and 2.
Ms Hamilton, for the NMC, read into the record the witness statements of:
• Ms 3, Senior Midwife at the Trust, qualified in 1988;
• Ms 4, Band 6 Midwife at the Trust, qualified in 1985;
• Ms 5, Midwife (at the Trust since 1989), Maternity Risk Manager (2003) and
Supervisor of Midwives (2002);
• Dr 10, an ST4 and employed by Pennine Acute Hospital NHS Trust on placement
at Furness Hospital;
• Ms 11, Divisional Governance Lead for Acute and Emergency Medicine at the
Trust;
• Ms 12, Community Midwife Manager and a Supervisor of Midwives at the Trust;
• Ms 13 Midwife (since 1987) and Matron of Maternity Services since 2012 at the
Hospital;
• Ms 14, Midwife (since 1983), Matron for Community midwifery, Antenatal clinic and
Gynaecology at the Lancaster Royal Infirmary until 2012;
• Ms 16 Midwife (since 1987), Antenatal Clinic Lead Midwife in Furness Hospital at
the Trust and a Supervisor of Midwives;
• Ms 18, Senior Midwife and Co-ordinator of Labour for the past six years at Trust;
and
• Ms 19, Community Midwife (since 1994), Community Midwife Manager and
Supervisor of Midwives.
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Further, Ms Hamilton read into the record a letter, dated 24 March 2015, from Ms Ratcliffe.
The panel acknowledged that Mrs Ratcliffe had admitted all the charges against her.
However, the panel decided to hear and read all of the evidence prior to making its
findings on the facts of this case.
Charge 1 Patient A told the panel that Baby B was her third baby and her expected date of delivery
(EDD) was 18th February 2004. During her pregnancy, Patient A was admitted at 38
weeks gestation (4 February 2004) to monitor raised blood pressure (‘BP’) and after this
admission the hospital scanned Patient A to estimate the foetal growth. Patient A stated
she was an obese woman and Baby B’s birth weight was estimated to be 10lb 10oz. On
10th February, Consultant Dr 1 agreed to induce the labour, as Patient A was
uncomfortable.
On 17th February 2004 induction with prostaglandin failed and Patient A was readmitted on
the 23rd February for further prostaglandin on 24th February but progress was slow. On
25th February 2004 Dr 1 performed a stretch and sweep of Patient A’s cervix at
approximately 15:30. Later that afternoon, an antenatal ward midwife performed a vaginal
examination when Patient A felt an urge to push and her cervix was found to be 5-6cm
dilated.
Staff transferred Patient A to the care of Mrs Ratcliffe on the labour ward at approximately
18:30. Patient A advised Mrs Ratcliffe that she was a strep’ B carrier and required
antibiotics but Mrs Ratcliffe informed her that it was too late to give the medication. Mrs
Ratcliffe examined Patient A again and found her cervix to be 9cm dilated. At
approximately 19:30-19:45 Patient A recalls that Dr 2 performed an artificial rupture of
membranes (ARM), instructed Mrs Ratcliffe to place her in the McRobert’s position and
said that he would wait on the ward. Patient A said she did not see him again. Patient A
remembers that Mrs Ratcliffe auscultated the fetal heart rate (FHR) on three or four
occasions using a sonic aid.
At 20:15, Patient A was in the second stage of labour.
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Patient A used gas and air to help with the pain and Mrs Ratcliffe encouraged her to push
with contractions. She asked Mrs Ratcliffe to perform an episiotomy to deliver the baby
quickly and safely but Mrs Ratcliffe told her it was not necessary.
At 20:40 midwives Ms 3 and Ms 4 came in to the room and Mrs Ratcliffe then performed
an episiotomy and delivered Baby B at 20:58 and placed her at Patient A’s side. Patient A
told the panel that she saw that her baby was purple, blue and lifeless. Further, Patient A
told the panel that Baby B’s head ‘flopped’ down. Ms 4 then took Baby B from the room
for resuscitation and Mrs Ratcliffe stayed to deliver the placenta.
Baby B was transferred to the neonatal unit at Liverpool Women’s Hospital where she died
on 26th February 2004 close to midnight but the death was certified on 27th February 2004.
The cause of death was hypoxic ischaemic encephalopathy and heart and kidney failure.
Baby B’s parents attended the coroner’s inquest on 23rd and 24th September 2013.
Ms 4 in her statement stated that she attended the delivery of Patient A who was an obese
woman expecting a large baby. She stated that Mrs Ratcliffe had already anticipated
difficulty with the baby’s shoulders and the patient was in the McRobert’s position when
Ms 4 entered the room at 20:40. She attempted to auscultate the FHR at 20:53 but was
not successful. Ms 4 stated that she was not aware whether there had been earlier
difficulties in hearing the FHR; further she did not know what time Patient A had gone in to
the second stage of labour.
Ms 3 in her statement stated that she does not remember the time that she entered
Patient A’s room. She stated that Mrs Ratcliffe may have left the room between 20:20 and
20:58 to get equipment to assist with the delivery. She stated she was aware that Dr 2 was
on labour ward awaiting the outcome and that she discussed with Mrs Ratcliffe whether
she should perform an episiotomy to expedite delivery of the expected large baby. Ms 3
stated that she remembers that Ms 4’s attempt to listen to the FHR was unsuccessful. Ms
3 stated that Baby B was unresponsive at birth and she attempted with Ms 4 to resuscitate
Baby B until the paediatric team arrived.
Ms 5 was employed as the Maternity Risk Manager in 2004 and had the additional
responsibility of Supervisor of Midwives North West Local Supervising Authority
(“SMLSA”). The Head of Midwifery instructed Ms 5 to review the clinical care delivered to
Patient A. She did this by using Patient A’s notes only and no witness were interviewed or
21
statements taken from them as to what happened that night. Ms 5 noted that the fetal
heart rate had not been recorded at 5-minute intervals during the second stage of labour
contrary to the NICE Guidelines for Normal Labour.
Following this review, Mrs Ratcliffe attended a meeting with the Ms 6, the Head of
Midwifery, and Ms 5 on 19th May 2004 during which Mrs Ratcliffe said that she had
difficulty auscultating the FHR and had not realised how quickly the time had passed.
Ms 6 requested that Mrs Ratcliffe and Ms 5 should attend a study day but it is unclear to
the panel as to the title of the study day, what area of practice or risk assessment it
addressed, or when it took place.
The panel heard that the NMC instructed Ms 7 to provide an expert opinion in relation to:
1. fetal heart monitoring;
2. medical assistance; and
3. causation.
Ms 7 referred to the relevant professional standards in place at that time: The NMC Code
of Professional Conduct (2002) and UKCC Midwives Rules and Code of Practice (1998).
In Ms 7’s opinion, Patient A should have been identified as a high risk woman due to her
obesity, history of pre-eclampsia and expected large baby. In the circumstances, and in
accordance with the NICE Guidelines 2001, continuous electronic foetal monitoring was
clearly indicated and a referral should have been made to the doctor who was waiting on
the ward. In failing to follow guidelines in place at that time, Mrs Ratcliffe missed a vital
opportunity of identifying early concerns with the baby’s heart rate.
Charge 1.1
1. On 25 February 2004 and in relation to Patient A 1.1 Failed to adequately monitor the fetal heart rate after 20:15 and up until the time
that Patient A’s baby was delivered
The panel found that Mrs Ratcliffe was the Midwife in charge of Patient A’s labour and
Baby B’s delivery and owed both Patient A and Baby B a duty of care.
22
Based on the evidence of Ms 7, the panel found that Mrs Ratcliffe was under a duty to
identify and be aware of any risks to Patient A or Baby B. This was to ensure that the
delivery progressed safely. The panel heard that Patient A had a raised and unstable
blood pressure, a high Body Mass Index, a ‘large baby’, hypertension and she was a strep’
B carrier. The panel heard evidence that this indicated that Patient A was a high risk
patient and therefore needed to be monitored and managed as a high risk patient.
The panel noted from the evidence that the last time Baby B’s heart rate was observed
and recorded during labour was at 20:15. The panel noted that Patient A’s partogram is
completely blank. The panel noted that there is no evidence or record of CTG monitoring.
The only recording is in Patient A’s notes at 20:15 in which it is recorded that:
‘FH [foetal heart] 130 – 140 bpm, no decelerations.’
Baby B was born at 20:58 and the panel noted that there are no other recordings or
evidence to suggest that Baby B’s heart rate was monitored between 20:15 and 20:58.
The panel noted that Patient A told the panel that after 20:15 Mrs Ratcliffe did not monitor
Baby B’s heart rate.
Ms 7 told the panel that Mrs Ratcliffe should have used a foetal electrode to monitor the
heart rate. Further, she stated that at 20:20 there was a missed opportunity to get help or
use a CTG. In addition, Ms 5 in her witness statement stated:
‘The foetal heart rate should have been listened to every five minutes in
accordance with the guidelines.’
The panel accepted Ms 7’s conclusion that Patient A should have been identified as a high
risk woman due to her obesity, history of pre-eclampsia and large baby. In the
circumstances and in accordance with the NICE Guidelines 2001 continuous electronic
foetal monitoring was necessary.
The panel found that in accordance with the NICE guidelines Mrs Ratcliffe was under a
duty to monitor Baby B’s heart rate. However, the panel found no evidence that Baby B’s
heart rate had been monitored between the 20:15 and 20:58. Accordingly, the panel found
charge 1.1 proved.
23
Charge 1.2
1.2 Failed to request assistance from a Doctor and/or any other suitably qualified medical professional when you had difficulty auscultating the fetal heart.
The panel noted Ms 5’s written statement in which she stated:
‘Generally speaking, it is accepted practice that if there is a difficulty locating the
foetal heart rate then a foetal scalp electrode should be used…However, if Marie
[Mrs Ratcliffe] had difficulties locating the foetal heart and it was inappropriate to
use a foetal scalp electrode, she should have sought medical assistance from the
doctor who was already on the labour ward.
…Having reviewed the clinical notes, in my clinical opinion, Marie should have
contacted the doctor who was on standby on the ward when she could not locate
the foetal heart rate. She had documented that she had difficulty locating the foetal
heart rate at 20:30 and therefore, she should contacted Dr 2 to attend to Patient A
at or before 20:30.’
Ms 7 agreed with Ms 5. She told the panel that Mrs Ratcliffe should have sought medical
assistance at 20:20 when she could not auscultate the foetal heart rate. Patient A
confirmed to the panel that Dr 2 did not come in.
The panel noted from Patient A’s notes that Mrs Ratcliffe had attempted but failed to
auscultate Baby B’s heart rate.
The panel, based on the evidence of Ms 5, Ms 7 and Patient A, along with Mrs Ratcliffe’s
admission to this charge, found that Mrs Ratcliffe failed to request assistance from a
Doctor or any suitability qualified medical professional when she had difficulty auscultating
the foetal heart.
Accordingly, the panel found charge 1.2 proved.
Charge 1.3
1.3 Caused distress to Patient A by inappropriately placing Patient A’s baby by her side
24
Patient A told the panel:
‘On Baby B’s delivery Marie [Mrs Ratcliffe] placed her onto my left side and as
soon I looked at her I could see that something was very wrong. Baby B was
purple and blue in colour and when I touched her, her head flopped. Baby B looked
as though she had died. I asked Marie what was wrong with Baby B, at which point
Midwife Ms 4 picked Baby B up and ran out of the room with her. I remember
seeing Midwife Ms 4 holding Baby B up in front of her with both hands. Midwife Ms
3 remained in the room for a few minutes after Baby B’s delivery and then left
before Marie delivered the placenta.’
As a consequence, Patient A told the panel that due to the psychological effect on her of
Baby B’s death she asked to be sterilised following the birth of her fourth child. Patient A
told the panel that she found Mrs Ratcliffe to be dismissive and that she felt uncomfortable
around her. Patient A told the panel that Mrs Ratcliffe’s demeanour and attitude were
different to other midwives who had cared for her. She said that Mrs Ratcliffe did not
explain anything to her.
Patient A told the panel about Mrs Ratcliffe’s comments to the coroner, at the inquest of
Baby B. When asked by the coroner why she had placed the baby by Patient A’s side, Mrs
Ratcliffe responded by asking where else was she supposed to put it.
The panel concluded, under any possible interpretation of events, that the correct
procedure when Patient A delivered Baby B, who was ‘purple and blue’, was to take Baby
B immediately to the rescusitaire. The panel determined that any competent midwife would
have known that it would have been inappropriate, given Baby B’s condition, to put Baby B
on the side Patient A.
Based on all the evidence above, the panel found charge 1.3 proved.
Charge 1.4 (i)
1.4 Your conduct: i) contributed to the death of Patient A’s baby and/or;
Ms 7 told the panel that the midwives code of practice identifies that ‘as a midwife, you
have defined sphere of practice and you are accountable for that practice. The needs of
the mother and baby must be the primary focus of your practice…’
25
Ms 7 was asked in her report by the instructing solicitor the extent to which she agreed
with statement that Mrs Ratcliffe contributed to Baby B’s death, she agreed and stated:
‘This was a pregnancy with a high risk of complications in labour and if continuous
electronic fetal heart monitoring had been carried out, using a fetal scalp electrode,
then the opportunity would have been available to identify with the fetal heart rate
which could have been acted on earlier.’
The panel has already found that Patient A was a high risk patient who should have been
on continuous monitoring, as per the NICE Guidelines at the time of these events; and that
at around 20:20 when Mrs Ratcliffe could not auscultate Baby’s B heart rate she should
have called for the assistance of a doctor.
Based on the expert evidence of Ms 7, the panel agreed that Mrs Ratcliffe contributed to
Baby B’s death by failing to continuously monitor Baby B’s heart rate, from 20:15 to
delivery at 20:58. This failure resulted in missed opportunities to identify concerns and or
to call medical assistance.
Accordingly, the panel found charge 1.4 (i) proved.
Charge 1.4 (ii)
1.4 Your conduct: ii) caused Patient A’s baby to lose a significant chance of survival.
The panel considered it unnecessary to consider charge 1.4 (ii) in light of its finding in
charge 1.4 (i).
For the avoidance of doubt, charge 1.4 (ii) is found not proved.
Charge 2 Patient B told the panel that she was scared about the size her baby would be at labour.
She told the panel that midwives at the hospital during the antenatal clinic appointments
had joked about the anticipated size of her baby.
She stated that the nurses and doctors did not explain what was happening.
26
Patient B told the panel that Mrs Ratcliffe didn’t make her feel comfortable. She stated that
Mrs Ratcliffe made no effort to build a rapport with her and there was no trust there.
Patient B said that Mrs Ratcliffe had said that an epidural was not in her birth plan. This
was clearly wrong as it was written in the birth plan which was shown to the panel.
Patient B told the panel that the midwives were aloof and treated her coldly to her when
she finally left which made her feel like she had done something wrong.
During the course of her labour, Patient B said that the doctor was told by Mrs Ratcliffe
that he wasn’t needed.
Patient B told the panel that there was delay between when the doctor put his head
around the door to introduce himself, getting changed into scrubs and returning to Patient
B.
Patient B told the panel that Baby C was her second baby. She stated that her first child
was a normal delivery in 2005 but was followed by a post-partum haemorrhage (PPH)
requiring a 3-unit blood transfusion. The baby weighed 8lb 6oz. Patient B wanted full
hospital care because of the complications of her first delivery. Her due date was 5
September 2008.
Patient B had a number of scans at 32, 36 and 39 weeks of pregnancy because Baby C’s
growth was on the 95th percentile at 32 weeks and the estimated birth weight at the 39
week scan was 10lb 11oz. On 4 September 2008 Patient B spoke to consultant
obstetrician Dr 1 to request induction of labour and he agreed to induce her. On the
evening of 4 September 2008 Associate Specialist Dr 20 administered prostin and the
following morning, 5 September 2008, Patient B’s cervix had dilated but Dr 20 did not
return to perform an ARM (‘artificially ruptured membrane’) procedure.
On 6th September 2008 between 9:10 and 9:30, Patient B was admitted to labour ward,
transferred to the care of Mrs Ratcliffe and Dr 20 assessed Patient B whom he had
accidently ARM’ed during an examination and noted her cervix was 4 cm dilated. He noted
that the presenting part was still -3cm above the ischial spines and the patient would need
syntocinon in view of the large baby. The plan was to observe Patient B for four hours.
27
At some point, Patient B asked for a caesarean section. Patient B told the panel that Mrs
Ratcliffe replied sarcastically to her, stating ‘If only everyone who wanted a caesarean
section got one on a whimper.’
Ms 7 stated that in the first stage of labour Mrs Ratcliffe recorded the Foetal Heart Rate
every 30 to 60 minutes. Maternal observations of temperature, pulse and blood pressure
were recorded at 13:30 and further blood pressure recordings were made at 16:00 and
19:00. Urine output was documented at 13:30 and 19:30.
Ms 7, the expert witness, in her report stated that:
‘Following second stage of labour being identified at 19:45 pushing was encouraged.
Progress was identified as slow. Good contractions were documented.’
Patient B recalls that she was in a substantial amount of pain throughout labour and she
was eventually told to push with her contractions but felt that she was making little
progress.
At 17:30, cervical rim was felt with the head still at -2cms above the spine. At 18:15, in
Patient B’s notes it stated that ‘Expected signs of further progress in labour not seen.
Vaginal examination showed that the head remained high. Contractions were expulsive
and patient was pushing.’
At 19:54 Dr 21 entered the room to assess Patient B’s progress but Mrs Ratcliffe informed
him that delivery was imminent so he stood at the door of Patient B’s room. At 21.00
Midwife Ms 18 took over Patient B’s care and she left the room to get Dr 20 who went to
prepare for an instrumental delivery. Patient B recalled that Mrs Ratcliffe came back in the
room and both midwives and the doctor encouraged her to push as she was positioned on
all fours. After the next contraction Mrs Ratcliffe felt the cord wrapped tightly around the
baby’s neck.
Patient B remembers that she was thrown on to her back; Dr 20 performed an episiotomy
to deliver Baby C who was born at 21:39 and weighed 11lb 13oz. The baby was taken
from the room and the consultant paediatrician Dr 23 who informed Patient B that Baby C
had been stillborn.
28
Charge 2.1 (i) and (ii)
2. On 6 September 2008 in relation to Patient B
2.1 In relation to Patient B’s pain relief; i) Advised Patient B that she could not have an epidural ii) Failed to document your discussions with Patient B regarding pain
Patient B told the panel that, at around 11:50 on 26 September 2008, she told Mrs
Ratcliffe that epidural was in her care plan but Mrs Ratcliffe refused to give it. Patient B
told the panel that Mrs Ratcliffe offered her pethidine instead, which she consented to.
Patient B told the panel that she was in so much pain she would have had anything but
stated that the pethidine was ineffective.
However, it was only after being given pethidine that Patient B was told by Mrs Ratcliffe
that because she had been given pethidine she could not have now have an epidural.
The panel, based on the evidence of Patient B, found that Mrs Ratcliffe did advise Patient
B that she could not have an epidural. Accordingly, charge 2.1 (i) is proved.
The panel noted Patient B’s notes and found no discussion between Mrs Ratcliffe and
Patient B regarding the administration of an epidural. Ms 7 in her report stated:
‘I would expect a responsible body of reasonably competent midwives to have
discussed pain relief options available when taking over care of a client in early
labour, to include the availability of an epidural, whether or not a birth plan was
written, this is not evident at any stage following admission for induction of labour on 4
September 2008 nor admission to labour ward on 6 September 2008.’
Further, Ms 7 stated:
‘There is no documented evidence at any stage when caring for Patient B that Marie
Ratcliffe enabled Patient B to make an informed choice regarding choice of an
epidural for pain relief. My opinion is that Marie Ratcliffe did not act in accordance with
a responsible body of competent midwives with regard to her discussions or
documentation relating to pain relief options in labour.’
29
The panel found based on the evidence of Ms 7 and Patient B’s notes, that Mrs Ratcliffe
failed to document her discussions with Patient B regarding pain relief. Accordingly, the
panel found charge 2.1 (ii) proved.
Charge 2.2 2.2 Failed to monitor the fetal heart rate at 15-30 minute intervals during the first stage of
labour; Ms 7 in her report stated that:
‘Fetal heart monitoring should have been undertaken as per NICE guidance (NICE,
2007). This did not occur and in my opinion the standard of care by Marie Ratcliffe
with regard to fetal heart monitoring, did not meet the standards expected by a
responsible body of reasonably competent midwives working on a labour ward.’
The panel were provided with the NICE guidance 2007 and found that Mrs Ratcliffe was
under a duty to monitor the foetal heart rate every 15 to 30 minutes. The panel were also
provided with Patient B’s notes and found that Mrs Ratcliffe did not monitor the foetal heart
rate every 15 to 30 minutes. Accordingly, the panel found charge 2.2 proved.
Charge 2.3 (i) to (iv) 2.3 Failed to observe and/or record the following:
i) The maternal temperature at four hourly intervals
ii) Maternal blood pressure at four hour intervals in the first stage of labour
iii) Maternal blood pressure at hourly intervals in the second stage of labour
iv) Maternal pulse at hourly intervals
The panel were provided with the NICE Guidance which stated that:
‘Observations by a midwife during the first stage of labour should be recorded on
a partogram and include 4 hourly temperature and blood pressure…hourly pulse
[and] during the second stage of labour should be recorded on the partogram and
include…hourly blood pressure.’
30
Ms 7 in her report stated that
‘there is no evidence in the handwritten records of any maternal observations..
The partogram documents a set of observation of temperature, pulse and blood
pressure at 13:30, a pulse and blood pressure at 16:00, a temperature at 18:30
and blood pressure at 19:30….In my opinion, I would expect that a responsible
body of reasonably competent midwives would have met the standards above for
maternal observations and recorded them in the partogram and or in the
handwritten records….In my opinion Marie Ratcliffe did not meet the standards…’
In relation to charges 2.3 (i) to 2.3 (iv) the panel found no evidence or recordings in either
the Patient B’s notes or on the partogram to show that Mrs Ratcliffe observed maternal
temperature at four hourly intervals, maternal blood pressure at four hour intervals in the
first stage of labour, maternal blood pressure at hourly intervals in the second stage of
labour or maternal pulse at hourly intervals.
Accordingly, the panel found charges 2.3 (i) to 2.3 (iv) proved.
Charge 2.4
2.4 After approximately 21.25 when you had resumed the care of Patient B you failed to adequately monitor and/or ensure that the fetal heart rate was being adequately monitored in that you:
i) Failed to maintain continuous electronic fetal monitoring and/or
ii) Failed to auscultate that the fetal heart rate every 5 minutes and/or
iii) Failed to auscultate the fetal heart rate after every contraction for one minute and/or
iv) Failed to apply a fetal scalp electrode to monitor the fetal heart rate The panel were provided with the Trust and NICE guidance on foetal heart rate monitoring
which stated that CTG monitoring should occur if risk factors are present.
Ms 7 told the panel that:
‘At 21:25 Marie Ratcliffe records the fetal heart at 155bpm. There is no indication of
when she heard it in relation to a contraction or for how long. Ms 18 in her statement
31
said that neither of them were successful in auscultating the fetal heart after 21:10.
No further attempt to listen to the fetal heart is identified although continuous
electronic fetal monitoring should have been in place at this stage or at least the fetal
heart auscultated every 5 minutes or after every contraction for 1 minute. In my
opinion the standard of monitoring undertaken by Marie Ratcliffe does not meet the
standard expected by a responsible body of competent midwives.’
Further, Ms 7 added:
‘I would have expected that continuous electronic fetal heart monitoring would have
been attempted when fetal tachycardia and decelerations were identified as per
hospital and NICE guidance.’
The panel found no evidence on either the partogram or in Patient B’s notes that Mrs
Ratcliffe maintained continuous electronic fetal monitoring, auscultated the fetal heart rate
every 5 minutes, auscultated the fetal heart rate after every contraction for one minute or
applied a fetal scalp electrode to monitor the fetal heart rate.
Accordingly, the panel found charges 2.4 (i) to 2.4 (iv) proved.
Charge 2.5 2.5 Failed to adequately escalate the delay in the second stage of labour to an obstetrician
at approximately 20:45 Ms 7 stated in her report:
‘Marie Ratcliffe discussed care of Patient B with Dr 21 when she commenced caring
for her at 08:30. She next requested assistance from Dr 21 at 19:45 when there was
potentially slow progress identified in second stage. However, when he [Dr 21]
arrived at 19:54 some progress was evident and he was not required any more. Dr
21 then waited in Labour Ward until 21:00 in case further assistance was required.
In my opinion a responsible body of reasonably competent midwives would have
made a referral to an Obstetrician after one hour of active (pushing) second stage
labour as recommended by NICE (2007) which was at the latest, 20:45.
32
However, there was no evidence that escalation was considered at this stage, and in
my opinion the care given by Marie Ratcliffe did not meet the standard expected by
a responsible body of reasonably of competent midwives.’
Patient B told the panel that Mrs Ratcliffe did not call for Dr 21 at 20:45.
The panel, based on the evidence of Ms 7 and Patient B, found that Mrs Ratcliffe was
under a duty to call Dr 21 when there was slow progress at the second stage of labour and
that she did not call for Dr 21 when she was under a duty to do so.
Accordingly, charge 2.5 is proved.
Charge 2.6 (i)
2.6 Your conduct: i) contributed to the death of Patient B’s baby and/or;
In a letter dated 30 June 2014 to Morgan Cole Solicitors Ms 7 provided a supplementary
document regarding causation and stated that, in her opinion, Mrs Ratcliffe’s failure to
monitor the baby’s heart rate thoroughly and her failure to escalate slow progress
contributed to the stillbirth of Baby C.
The panel found, based on the expert evidence of Ms 7, that Mrs Ratcliffe failed to carry
out fetal heart monitoring as frequently or as thoroughly as the standards dictated
throughout labour. If she carried out foetal monitoring as the standards dictated, deviations
from the normal are likely to have been identified which should have prompted her to
commence continuous electronic foetal monitoring. If this was in place, it is highly likely,
that fetal bradycardia would have been detected because of the umbilical cord being tight
around the baby’s neck. As such a vital opportunity to refer the matter for obstetric review
was missed.
It was Ms 7’s opinion that:
‘She [Mrs Ratcliffe] requested obstetric review at 19:54 as progress had been slow, as
per guidelines, but then retracted the request when the doctor arrived. If an obstetric
assessment had been made at this stage and a plan put in place, appropriate
preparations would have been made if progress continued to be slow or concerns
arose with the fetal heart monitoring. At 20:45 Marie Racliffe documented “slow
33
advance of the head” and if she had escalated her concerns at this point and
requested obstetric opinion, there was potential for the delivery of a live baby.’
The panel, taking into account the clear evidence from Ms 7, found that Mrs Ratcliffe did
contribute to death of Baby C.
Accordingly, charge 2.6 (i) is proved.
Charge 2.6 (ii) 2.6 (ii) caused Patient B’s baby to lose a significant chance of survival
The panel considered it unnecessary to consider charge 2.6 (ii) in light of its finding in
charge 2.6 (i).
For the avoidance of doubt, charge 2.6 (ii) is found not proved.
Charges 3 to 13
Further to the death of Baby C, an external report was completed by the acting Head of
Midwifery at the Royal Bolton Hospital. Further to that report’s publication, Ms 17 who was
Head of Midwifery at Furness General Hospital instructed Ms 15 and Ms 14 to review 11
randomly selected sets of intra-partum notes of patients who had been cared for by Mrs
Ratcliffe. Ms 15 was Matron of Gynaecology and Maternity at the Trust; Ms 14 was Matron
for Community Midwifery at Lancaster Royal Infirmary in 2009.
Following completion of the investigation report by Ms 14 and Ms 15, Ms 17 instructed Ms
16, who is a Supervisor of Midwives (‘SOM’), to carry out a supervisory investigation on
the same patient notes.
Charges 3 to 13 arise from the reviews of the 11 sets of notes.
Ms 16, SOM, met with Mrs Ratcliffe on 1 March 2010. She recommended 150 hours of
supervised practice and submitted her investigation to the LSAMO, who agreed with her
findings.
Following submission of Ms 14 and Ms 15’s report, Mrs Ratcliffe’s conduct was considered
at a disciplinary hearing on 7 May 2010 chaired by the Trust Head of Business and
34
Performance. At the conclusion of the hearing that panel recommended 120 hours of
supervised practice but agreed with the LSA proposal of 150 hours of supervised practice
and issued a first written warning.
Ms 16 attended a meeting regarding the implementation of supervised practice of Mrs
Ratcliffe on 19 May 2010 and Mrs Ratcliffe completed the programme, which included
proficiency in the use and interpretation of CTG monitoring and a reflective essay, by
September 2010.
Charge 3
3. On 11 and/or 12 June 2009 when delivering intrapartum care to Patient D: 3.1 Did not monitor and/or record the temperature of the birthing pool as required; 3.2 Did not document the reason why you artificially ruptured Patient D’s membranes; 3.3 Did not monitor and/or record the maternal observations; 3.4 Did not ensure that Patient D’s urine was tested and/or record that you had tested Patient D’s urine or 3.5 In the alternative to charge 3.4 above failed to record the reason for not testing Patient D’s urine
Patient D self-referred to the labour ward on 13 June 2009 at 05:40 and Mrs Ratcliffe took
over her care at 08:00.
Ms 15 stated that Patient D went into the birthing pool at 17:00 but Mrs Ratcliffe did not
record the temperature of the water contrary to the Trust Guidelines “Birthing Pool Policy
2006”. Further, maternal observations were not monitored and recorded with the
frequency required by NICE Guidelines for Intra-partum Care. During an examination at
19:00, Mrs Ratcliffe performed an ARM but gave no reason for the procedure in Patient
D’s notes.
Ms 16 in her witness statement stated that Mrs Ratcliffe had not tested Patient D’s urine
during labour nor recorded the reason for not doing so.
35
The panel were provided with Patient D’s notes and found no evidence that Mrs Ratcliffe
recorded: the temperature of the birthing pool, the reason why she artificially ruptured
Patient D’s membranes, maternal observations or the reason for not testing Patient D’s
urine.
Mrs Ratcliffe’s response to the Trust investigation was that she would have taken the
temperature of the birthing pool but that she hasn’t written it. Further, she stated that the
fact that she has not documented Patient D’s observations does not mean that she has
not done them. She asserted she would have done them. In relation to the ARM, she
stated that someone must have stated that ARM was required.
The panel found charges 3.1 to 3.3 proved as it found no evidence of any recordings
regarding maternal observations, the temperature of the birthing pool or the reason why
she artificially ruptured Patient D’s membranes. In relation to charge 3.1 the panel found it
more likely than not that Mrs Ratcliffe did not monitor the temperature of the birthing pool
at all.
In relation to charge 3.4, the panel noted Mrs Ratcliffe cared for Patient D between 17:00
and 21:20. The panel noted from Patient D’s partogram that it is recorded that Patient D
passed urine at 17:00 and 19:00. Mrs Ratcliffe was under a duty the test the urine and
make a record of that test. The panel determined that it was insufficient to only record ‘PU’
[passed urine]. The panel found no evidence in either Patient D’s notes or Patient D’s
partogram that Patient D’s urine had been tested or recorded. Accordingly, the panel
found charge 3.4 proved.
As the panel found charge 3.4 proved and charge 3.5 is in the alternative, the panel did
not consider charge 3.5. The panel therefore found charge 3.5 not proved.
Charge 4
4. On 9 February 2009, when delivering intrapartum care to Patient E: 4.1 Did not monitor and/or record maternal observations
i) During the birth and/or ii) After the birth
4.2 Did not document any records on the partogram
36
The panel were provided with Patient E’s notes and partogram.
Patient E referred herself in spontaneous labour with her fourth baby at 16:00 on 9
February 2009 and delivered at 16:50. Ms 14 and Ms 15 both acknowledge that Patient
E’s labour was short but noted that basic observations should still be done while the
woman was in labour and post-natally. Mrs Ratcliffe failed to do basic observations or
record these contrary to the NICE Guidelines for Intra-partum Care. Further, Ms 14 stated
that Mrs Ratcliffe did not document any maternal observations on the partogram and
instead wrote ‘admitted in advance labour’.
Whilst the panel accepted that Patient E’s labour was short, it also accepted Ms 14’s
evidence that Mrs Ratcliffe should have documented the maternal observations. The panel
found no evidence that Mrs Ratcliffe monitored or recorded maternal observations during
labour or after the baby’s birth. Further, the panel found that Mrs Ratcliffe did not use the
partogram and left it blank, save for the words ‘admitted in advance labour’. The panel
found it more likely than not that Mrs Ratcliffe did not monitor the maternal observations at
all.
Accordingly, the panel found charges 4.1 (i), 4.1 (ii) and 4.2 proved.
Charge 5
5. On 17 February 2009, when delivering intrapartum care to Patient F: 5.1 Did not adequately document the reason why you artificially ruptured Patient F’s membranes; 5.2 Did not document any records on the partogram after you took over the care of Patient F 5.3 Did not monitor and/or record maternal observations during labour; 5.4 Did not monitor and/or record maternal postnatal observations 5.5 Failed to seek the advice of the Registrar for Patient F after 1 hour of Patient F having been in the active second stage of labour
The panel was provided with Patient F’s notes and partogram.
37
Patient F self-referred to labour ward on 17 February 2009 at 03.00 after an earlier
admission the day before in early labour with her second baby. Mrs Ratcliffe took over her
care at 07:45 and the baby delivered at 11:17. During Patient F’s labour, Mrs Ratcliffe
performed an ARM without any reason for doing so; she did not complete the partogram or
monitor maternal observations during labour or post-natally. Further, Mrs Ratcliffe allowed
Patient F to continue pushing after an hour before referral for medical advice.
The panel found no evidence that Mrs Ratcliffe: documented any reason why she
artificially ruptured Patient F’s membranes; documented any records on the partogram
after she took over the care of Patient F, monitored or recorded maternal observations
during labour; and monitored or recorded maternal postnatal observations.
Accordingly, the panel found charges 5.1 to 5.4 proved. In relation to 5.1 and 5.4, the
panel found it more likely than not that, Mrs Ratcliffe did not monitor the maternal
observations at all.
In relation to charge 5.5, Ms 16 in her statement stated that Mrs Ratcliffe should have
called for a doctor after Patient F had been pushing for an hour. She stated that this was in
accordance with Trust policy at the time, but could not remember the name of the policy.
The panel were provided with both the Trust policy and the NICE Guidelines 2007. The
panel found Mrs Ratcliffe was under duty to call a doctor if the labour lasted for more than
1 hour. Based on Patient F’s notes, the panel found that the labour did last for more than 1
hour and that Mrs Ratcliffe did not call for a doctor, when she should have done so.
Accordingly, charge 5.5 is found proved.
Charge 6
6. On 20 February 2009, when delivering intrapartum care to Patient G: 6.1 Did not record any records on the partogram 6.2 Failed to request suitable medical assistance when you encountered a cord prolapse; 6.3 Did not monitor and/or document the fetal heart rate between the cord prolapse and the baby’s delivery; 6.4 Did not fully assess and/or record a full description of the CTG in
38
the maternal notes 6.5 Did not record the rationale for using the “wood screw” manoeuvre 6.6 Did not seek assistance from the medical team when you realised that the baby’s head was caught by the umbilical cord and/or did not document that you had sought assistance
The panel was provided with Patient G’s notes.
Patient G was induced with a prostin pessary for post-maturity and transferred to the
labour ward at 13:25 on 20 February 2009 when Mrs Ratcliffe took over care and Patient
G delivered at 14:40.
Ms 14, in her witness statement stated:
‘When I reviewed this set of notes I was very concerned and I considered that
Marie’s documented practice represented dangerous care. Marie failed to use the
partogram, there was no documentation of fetal heart rate between the cord
prolapse being identified and the delivery of the baby, there was no description of
the CTG findings in the maternal notes and there was no evidence that assistance
was summoned after the cord prolapse became apparent. Also, there was no
recorded rationale for the use of the wood screw manoeuvre implemented by
Marie, which is a difficult manoeuvre.’
Ms 15 in her statement stated that failure to describe the CTG in the notes was a breach
of the Trust policy “Monitoring of the Fetal Heart 2006” (the panel were provided with a
copy of this policy) in which the mnemonic ‘Dr C Bravado’ is recommended.
Ms 14 in her statement stated that Mrs Ratcliffe in interview asserted that she would not
use a partogram for the second stage of labour and admitted that the foetal heart rate had
not been recorded. Mrs Ratcliffe said that she was occupied and her reaction was to
deliver the baby as quickly as possible in the emergency situation.
In relation to charge 6.1, Mrs Ratcliffe in the Trust interview stated it was not her normal
practice to use a partogram in the second stage of labour. The panel found that Patient G
was only 5 to 6cm dilated at 13:45 and the baby was not delivered until 14:40 there would
39
have been ample time to use a partogram. Accordingly, the panel found charge 6.1
proved.
In relation charge 6.2, Ms 15 in her witness statement stated:
‘Marie said that she thought she had asked the 2nd midwife to call for the
paediatrician although it was not written down. Marie did not recognise a failure to
deliver care appropriately as she said “I don’t know what other action anyone
would take in that circumstance.”…The Trust policy had a specific guideline in
place to govern the re requirements in the event of a cord prolapse. The
policy…stated that in the event of a cord prolapse “urgently summon to labour
ward obstetric registrar, obstetric SHO, paediatric SHO, senior midwife…”’
It is a basic midwifery principle that a cord prolapse is an emergency situation. This is
reflected in the Trust policy.
Accordingly, the panel found charge 6.2 proved.
In relation to 6.3, the panel found no evidence in Patient G’s notes that Mrs Ratcliffe
recorded the foetal heart rate between the cord prolapse and the baby’s delivery in Patient
G’s notes. Accordingly, the panel found charge 6.3 proved.
In relation to charge 6.4, Mrs Ratcliffe recorded at 14:15 that ‘CTG reassuring’ and at
14:40 ‘baby’s face becoming bluer’ but no recording of foetal heart rate or CTG. The panel
found no evidence that Mrs Ratcliffe recorded a full description of the CTG results as
required in the Trust policy. Accordingly, the panel found charge 6.4 proved.
In relation to charge 6.5, the panel noted Patient G’s notes and found no rationale for
using the ‘the woodscrew’ manoeuvre. Accordingly, the panel found charge 6.5 proved.
In relation charge 6.6, the panel noted Ms 16’s witness statement in which she stated:
‘While Marie showed initiative in performing this manoeuvre, I was concerned that
there was no documented references to Marie seeking assistance from the medical
team when she realised that Patient G’s baby’s head was caught by the umbilical
cord. I believe that Marie should have sought immediate assistance once she
40
realised that the umbilical cord was wrapped around Patient G’s baby’s head. The
safety of Patient G’s baby could have been compromised by Marie’s failure to
escalate care.’
The panel noted that Mrs Ratcliffe could have used the emergency call bell to summon
help and she said she thought she had asked a student midwife to call for a doctor.
However, the panel noted that the evidence is Mrs Ratcliffe did not summon help and no
help had been summoned as evidence by the absence of any endorsement on the notes
of any attending doctor at that time. The panel found it more likely that not that Mrs
Ratcliffe did not summon help and nor did she ask the student midwife to seek help, as it
is very unlikely a student midwife would fail to do so if she had been asked in such a
situation.
Further, the panel has found no evidence in Patient G’s notes or from Ms 14 and Ms 15’s
detailed investigation to suggest that Mrs Ratcliffe summoned assistance from the medical
team when she realised that the umbilical cord was wrapped around Patient G’s baby’s
head. Accordingly, the panel found charge 6.6 proved.
Charge 7 7. On 22nd June 2009 when delivering intrapartum care to Patient H:
7.1 Did not document the rationale for performing an artificial rupture of Patient H’s membranes 7.2 Did not document any records on the partogram; 7.3 Did not monitor and/or record the fetal heart rate 7.4 Did not document the maternal observations 7.5 Did not document that Patient H was given facial oxygen and/or that her position had been changed
The panel was provided with Patient H’s notes.
Ms 14 stated that Patient H had a history of long-term amphetamine addiction and arrived
in spontaneous labour. Mrs Ratcliffe admitted Patient H on 22 June 2009 at 05:30 and she
delivered by Ventouse delivery at 07:54. Mrs Ratcliffe did one set of maternal observations
only and failed to commence a partogram. At 06:00, Mrs Ratcliffe examined Patient H
vaginally and performed an ARM but did not document the rationale for the procedure.
41
The fetal heart rate became bradycardic at 07:20 but Mrs Ratcliffe did not turn the patient
to her left side and administer facial oxygen as indicated in the “UHMB Guideline
Monitoring the Fetal Heart 2006”, as set out in Ms 14’s report. Further, Mrs Ratcliffe did
not record the FHR on the partogram.
In relation to charge 7.1, the panel noted in Patient H’s notes that Mrs Ratcliffe noted
‘ARM’ but did provide any rationale for performing the ARM procedure. Mrs Ratcliffe, in
her trust interview, stated ‘I don’t know, probably, would have had a discussion.’ However,
the panel had no evidence that such a discussion took place because nothing is written in
the patient’s notes. The panel therefore found charge 7.1 proved.
In relation to charge 7.2, the panel found no evidence that Mrs Ratcliffe documented any
records on the partogram. Accordingly, the panel found charge 7.2 proved.
In relation to charge 7.3, the panel found evidence that Mrs Ratcliffe had monitored the
fetal heart rate, this can be found on the patients notes on 22nd June 2009 between 05:30
and 07:30, when Mrs Ratcliffe last recording noted a fetal bradycardia and that she then
handed the problem over to the day staff. Accordingly, the panel found charge 7.3 not
proved.
In relation to charge 7.4, the panel found no evidence that Mrs Ratcliffe recorded maternal
observations. Accordingly, the panel found charge 7.4 proved.
In relation to charge 7.5, the panel determined that for this charge to be proved it needed
to be proved that Patient H was given oxygen or that her position changed. The panel has
found no evidence that Patient H was given oxygen or that her position changed. Mrs
Ratcliffe stated in the Trust Interview Patient A had been in the left lateral position all of the
time. The panel, therefore, found charge 7.5 not proved.
Charge 8
8. On 5 March 2009 when delivering intrapartum care to Patient I; 8.1 Did not monitor Patient I in labour using a CTG as required; 8.2 Did not take Patient I’s bloods for “group and save” 8.3 Did not insert a venflon
42
8.4 Did not conduct and/or record maternal observations in labour 8.5 Did not conduct and/or record maternal postnatal observations 8.6 When you encountered a shoulder dystocia:
i) Failed to request medical assistance; or in the alternative ii) Did not record that you requested medical assistance and/or the outcome of
the request. 8.7 Did not record that Patient I had previously had heart surgery 8.8 Did not consider and/or record that you had considered that intrapartum antibiotics
may be required
The panel were provided with Patient I’s notes. The panel noted Patient I had a previous
emergency caesarean section in 2006 and previous history of heart surgery.
The panel noted that the care of Patient I caused particular concern to all three witnesses
(Ms 14, Ms 15 and Ms 16) who reviewed the notes and classified Patient I as high risk
because of her history. The panel noted that Patient I had an obstetric history of previous
emergency caesarean section in 2006 following induction for mild hypertension and post
maturity. Patient I also had a medical history of heart surgery as a baby.
The panel noted that Patient I’s plan of care had stated that she was to have a trial of scar
if she went in to spontaneous labour. On 3 March 2009 Patient I self-referred to the
hospital with SROM and stayed on the antenatal ward until the onset of labour when she
was transferred to the labour ward on 5 March 2009 at 02:10 when Mrs Ratcliffe took over
her care.
After delivery of the head, the Registrant encountered shoulder dystocia. She did not call
for medical aid and used the “wood screw’ manoeuvre to attempt to deliver the baby which
was unsuccessful and she proceeded to deliver the posterior arm and then the body. Mrs
Ratcliffe did not document any request for emergency assistance when shoulder dystocia
presented. The Registrant did not take or record post-natal observations; further she did
not document that the patient had had heart surgery and may have required antibiotics.
Patient I eventually progressed to a normal delivery of a 9lb 15oz (4.520kg) baby.
43
In relation charge 8.1, the panel found no evidence in Patient I’s notes that Mrs Ratcliffe
monitored Patient I in labour using a CTG as required. The panel, therefore, found charge
8.1 proved.
In relation to charge 8.2, the panel found no evidence in Patient I’s notes that Mrs Ratcliffe
took Patient I’s bloods for “group and save”. The panel, therefore, found charge 8.2
proved.
In relation to charge 8.3, the panel found no evidence in Patient I’s notes that Mrs Ratcliffe
inserted a venflon. The panel noted Mrs Ratcliffe admission that she did not do it as, if was
required, it could be done in minutes. The panel heard evidence that while it could be done
quickly, under normal circumstances, attempting to insert a venflon in late stages of labour
when so much was happening at once would be difficult and would put the patient at risk.
The panel, therefore, found charge 8.3 proved.
In relation to charge 8.4, the panel found no evidence in Patient I’s notes that Mrs Ratcliffe
recorded maternal observations. The panel, therefore, found charge 8.4 proved.
In relation to charge 8.5, the panel found no evidence in Patient I’s notes that Mrs Ratcliffe
conducted or recorded post-natal observations. Mrs Ratcliffe in the Trust interview stated
that she was sure she would have done them, but only in relation to blood pressure, and it
was just that she hadn’t written them down. The panel, therefore, found charge 8.5 proved
in that Mrs Ratcliffe failed to record post-natal observations.
In relation to charge 8.6 (i), the panel was provided with the Trust ‘Shoulder Dystocia’
policy. The panel noted that the policy is clear that Mrs Ratcliffe should have requested
medical assistance when she encountered a shoulder dystocia. Mrs Ratcliffe stated at the
Trust interview that she had asked for a monitor and also requested medical assistance.
This was not recorded in the patient notes and further no doctor had written in these notes.
Accordingly, the panel found this charge proved.
In relation to charge 8.6 (ii), as it is in the alternative to 8.6 (i), the panel found it not
proved.
44
In relation to charge 8.7, the panel found no evidence in Patient I’s notes that Mrs Ratcliffe
recorded that Patient I had previously had heart surgery. Therefore, the panel found
charge 8.7 proved.
In relation to charge 8.8, the panel had no evidence that Patient I had been prescribed
antibiotic, therefore this charge is not proved.
Charge 9
9. On 23 February 2009, when delivering intrapartum care to Patient J;
9.1 Did not record the fetal heart rate in the text section of the maternal notes; 9.2 Did not conduct and/or record abdominal palpations 9.3 Did not record a description of the liquor after Patient J’s membranes were ruptured 9.4 Did not ensure that the administration of syntometrine in third stage labour was recorded in the electronic notes
The panel was provided with Patient J notes.
Patient J arrived on labour ward on 23 February 2009 at 10:50 in established labour. Mrs
Ratcliffe took over Patient J’s care and on vaginal examination at 11:15 found that the
cervix had dilated to an anterior rim only. Labour progressed to a normal delivery at 11:28.
In relation to charge 9.1, the panel found no evidence in Patient J’s notes that Mrs Ratcliffe
recorded the fetal heart rate in the text section of the maternal notes. The panel, therefore,
found charge 9.1 proved.
In relation to charge 9.2, the panel found no evidence in Patient J’s notes that Mrs Ratcliffe
conducted or recorded abdominal palpations. The panel, therefore, found charge 9.2
proved.
In relation to charge 9.3, the panel found this charge, as accepted by the NMC, not proved
as this event took place prior to Mrs Ratcliffe taking over the care of Patient J.
45
In relation to charge 9.4, the panel found no evidence in Patient J’s electronic notes that
Mrs Ratcliffe that syntometrine had been recorded during third stage labour. The panel
noted Ms 14’s evidence in which Ms 14 stated that Ms Ratcliffe tried to pass the blame to
a student midwife for failing to record that syntometrine had been administered. The panel,
therefore, found charge 9.4 proved.
Charge 10
10. On 27 February 2009, when delivering intrapartum care to Patient K; 10.1 Failed to monitor and/or record Patient K’s blood pressure during labour; 10.2 Failed to monitor and/or record Patient K’s blood pressure after she delivered her baby. 10.3 Did not document the dosage of syntocinon that was administered to Patient K during labour
The panel was provided with Patient K’s notes.
Patient K was admitted at 41 weeks gestation on 27 February 2009 for induction of labour
because of raised blood pressure, proteinuria and oedema. This was her second baby. At
10:00, Patient K had a prostin pessary administered by a midwife and at 15:00 the ward
staff transferred her to the labour ward where Mrs Ratcliffe took over her care. Ms 14 and
Ms 15 defined Patient K as a high-risk woman.
Patient K had a normal delivery at 15.18.
In relation to charge 10.1, the panel found that whilst Mrs Ratcliffe failed to monitor Patient
K’s blood pressure, she was only admitted to the labour ward at 15:10 and delivered at
15:18 therefore she would have only of had 8 minutes to monitor which the panel
determined was insufficient time. The panel therefore found this charge not proved.
In relation to charge 10.2, the panel found no evidence in Patient K’s notes that Mrs
Ratcliffe monitored or recorded Patient K’s blood pressure after the birth. The panel found
that there would have been ample time to do so and the failure to do so was contrary to
the Trust’s Guideline “Eclampsia and Pre-Eclampsia 2005. The panel, therefore, found this
charge proved.
46
In relation to charge 10.3, the panel found no evidence in Patient K’s notes that Mrs
Ratcliffe recorded the dosage of syntocinon that was administered to Patient K. The panel,
therefore, found charge 10.3 proved.
Charge 11
11. On 15 July 2009, when delivering intrapartum care to Patient L:
11.1 Did not provide a clear interpretation of the CTG in the Patient notes and /or
11.2 Failed to undertake an effective assessment of the CTG 11.3 Did not monitor and/or record the maternal pulse at the start of the
CTG; 11.4 Did not effectively monitor the fetal heart rate during the second stage of labour and/or failed to record the fetal heart rate on the partogram during the second stage of labour
The panel were provided with Patient L’s notes.
Ms 14 and Ms 15 define Patient L as a high-risk patient as she had had an emergency
lower segment caesarean section (LSCS) in 2004 for a baby over 4kg and the second
baby was expected to be on the 90th centile. Patient L presented to the labour ward at
12:00 on 15 July 2009 at 39 weeks and 6 days gestation and expressed a wish to have a
vaginal delivery.
Mrs Ratcliffe examined Patient L at 12.15 and found her to be 6-7cms dilated and she
referred the patient to the obstetric registrar who planned for labour to continue with
Continuous Electronic Fetal Montioring ‘CEFM’ in place. Mrs Ratcliffe continued to care for
Patient L who had a normal delivery at 16.30. The baby weighed 9lb 4oz (4.190kg).
The panel noted from the Trust review of Patient L’s notes, Ms 14 and Ms 15 stated Mrs
Ratcliffe failed to record the maternal pulse at the beginning of the CTG and thereafter
failed to clearly interpret and assess the CTG or record the FHR on the partogram in the
second stage of labour.
47
In her statement, Ms 14 stated that Mrs Ratcliffe should have used the advanced life
support in obstetrics (ALSO) mnemonic, Dr C Bravado, to correctly address each element
of interpretation in accordance with the Trust’s Policy “Monitoring of the Fetal Heart 2009”.
However, in relation to charge 11.1, the panel found this charge not proved as Mrs
Ratcliffe did provide an interpretation of the CTG results at 13:00 and 14:00. Accordingly,
the panel found this charge not proved.
In relation to charge 11.2, the panel found from Patient L’s notes that Patient L was being
monitored via CTG. Mrs Ratcliffe had made some assessment on the CTG between 15:00
and 15:45. However, the panel is unable to determine whether Mrs Ratcliffe’s assessment
of the CTG was effective without being provided a copy of the CTG data. Without the CTG
data, the panel is unable to make such an assessment and as such found charge 11.2 not
proved.
In relation to charge 11.3, the panel found that it was clear from Patient L’s notes that
when Mrs Ratcliffe took over care of Patient L at 12:00 she commenced CTG monitor and
recorded the maternal pulse. Accordingly, the panel found this charge not proved.
In relation to charge 11.4, the panel found that Mrs Ratcliffe did monitor the fetal heart rate
during the second stage of labour but that she documented her recording only in the
patient notes rather than on the partogram. The panel found that Mrs Ratcliffe failed to
record the foetal heart rate on the partogram during second stage of labour and therefore
charge 11.4 is proved.
Charge 12
12. On 4 April 2009, when delivering intrapartum care to Patient M:
12.1 Did not document the rationale for the artificial rupture of membranes; 12.2 Did not conduct and/or record maternal observations after you took over the care of the Patient M between 7:45 and 10.30; 12.3 Did not record the fetal heart rate on the text section of the notes; 12.4 Did not record that Syntometrine had been administered in the third stage of labour
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The panel was provided with Patient M’s notes.
The notes do not include the admission details but on 4 April 2009 at 06.50 Patient M was
on the labour ward and contracting every 3-4 minutes. Mrs Ratcliffe took over Patient M’s
care at 07:45 and performed a vaginal examination and ARM at 07:50 when the patient
was 9cm dilated. Patient M delivered normally at 08:25.
In relation to charge 12.1, the panel found no evidence in Patient M’s notes that Mrs
Ratcliffe documented the rationale for the ARM procedure. The panel, therefore, found
charge 12.1 proved.
In relation to charge 12.2, the panel found no evidence in Patient M’s notes that Mrs
Ratcliffe recorded maternal observations after she took over the care of Patient M between
7:45 and 10:30. The panel, therefore, found charge 12.2 proved.
In relation to charge 12.3, the panel found evidence in Patient M’s notes at 07:45 and at
07:50 that Mrs Ratcliffe recorded the fetal heart rate in the text section of the notes. The
panel, therefore, found charge 12.3 not proved.
In relation to charge 12.4, the panel found evidence in the electronic records that
syntometrine had been administered in the third stage of labour. The panel therefore found
that syntometrine had been recorded and that this charge was not proved.
Charge 13
13. On 12/13 August 2009, when delivering intrapartum care to Patient N: 13.1 Did not conduct and/or adequately record maternal observations; 13.2 Did not record the fetal heart rate on the partogram 13.3 Did not document a detailed description of the CTG trace in the notes 13.4 Did not record the dosage of syntocinon that was administered to Patient N; 13.5 Did not record the dosage of ergometrine that was administered to Patient N
The panel was provided with a copy of Patient N’s notes.
49
Patient N had a history of post-partum haemorrhage (PPH) with her first baby. Patient N
was admitted on 12 August 2009 at 08.45 when her contractions were 5 minutes apart.
Mrs Ratcliffe took over the care at 21:00 when the contractions were more frequent and
stronger. Mrs Ratcliffe carried out a vaginal examination at 21:00 and performed an ARM.
The contractions became milder and at 22:30 Mrs Ratcliffe examined Patient N again and
she was fully dilated. Mrs Ratcliffe discussed the slow progress with the doctor and started
a syntocinon intravenous infusion to augment labour at 22:30 and also commenced
CEFM.
At 22:50, 23:00, 23:15 and 01:15 Mrs Ratcliffe recorded “early decelerations” in the notes.
Patient N delivered normally at 00:25.
Mrs Ratcliffe administered syntometrine for the third stage and I/V ergometrine after the
patient continued to have a heavy bleed after delivery of the placenta.
In relation to charge 13.1, the panel found no evidence in Patient N’s notes that Mrs
Ratcliffe conducted or adequately recorded maternal observations. The panel therefore
found charge 13.1 proved.
In relation to charge 13.2, the panel found evidence that Mrs Ratcliffe did record the foetal
heart rate on the partogram. The panel found entries at 21:00 and at 22:00. In light of
these entries, the panel found this charge not proved.
In relation to charge 13.3, the panel found no evidence in Patient N’s notes that Mrs
Ratcliffe documented a detailed description of the CTG trace in the notes. The panel
therefore found charge 13.3 proved.
In relation to charge 13.4, the panel found no evidence in Patient N’s notes that Mrs
Ratcliffe recorded the dosage of syntocinon that was administered to Patient N. The panel
therefore found charge 13.4 proved
In relation to charge 13.5, the panel found no evidence in Patient N’s notes that Mrs
Ratcliffe recorded the dosage of ergometrine that was administered to Patient N. The
panel therefore found charge 13.5 proved.
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Further, and in any event the panel accept the cumulative issues of concern set out by Ms
14 and Ms 15 as a conclusion to their report:
• “Lack of or poor documentation generally, by particularly concerning the fetal heart
rate / CTG interpretation and the Partogram
• No set of notes reviewed contained a required standard of record keeping. The
recording keeping reflects substandard care
• Lack of recognition of high risk of high risk cases and non-adherence to guidelines
• Lack of evidence that assistance was summoned when deviations from normal
occurred
• Apparent reluctance to involve medical staff with care of women
• Liberal use of ARM, with no documented rationale
• All critical incidents not reported as per Trust policy
• Drug dosages not documented
• MR [Mrs Ratcliffe] is a student midwife mentor and was mentoring a first year
student midwife during some of these episodes. Mentors make judgements about
whether a student has achieved the required standard of proficiency for safe and
effective practice for entry to the NMC register. Mentors must demonstrate their
knowledge, skills and competence on an on-going basis.”
Charge 14
14. On 9/10 September 2013, when conducting a shift as Labour Ward Coordinator and in relation to Patient O; 14.1 Failed to check on Colleague A and/or Patient O between approximately 22.15 and 03.20; 14.2 Failed to request medical assistance when you became aware that the fetal heart rate was bradycardiac; 14.3 Failed to make accurate “fresh eyes” observation at around 22.15 in that you;
i) Documented that Patient O’s Labour was spontaneous when Patient O’s labour was in fact induced;
ii) Documented that there was no deceleration on the CTG when the CTG showed decelerations;
iii) Categorised the CTG as normal when it was in fact suspicious
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14.4 Failed to make any records in the “delivered by” section of Patient O’s notes despite having delivered the baby
After the supervised practice, Ms 16 became Mrs Ratcliffe’s named supervisor and she
was notified of a further incident that occurred on the night shift beginning 9 September
2013.
On 8 September 2013 at 08:00, Patient O was admitted to the Hospital for induction. The
reason for induction was because of a predicted large baby.
At 14:00, Patient O had a prostin pessary inserted and she stayed on the antenatal ward
overnight.
On 9 September 2013 the registrar examined Patient O and performed an ARM and a
syntocinon infusion was commenced at 13:45. Patient O was using Entonox and had
pethidine 100mg at 16.00. At 16:15, syntocinon was stopped due to a deceleration to
60bpm on the CTG that was monitored with a fetal scalp electrode.
The registrar assessed Patient O again at 19:05 and defined the patient as high-risk on
the ‘Dr C Bravado’ assessment. The registrar carried out a fetal blood sampling whose
result was normal.
Patient O requested and was given an epidural at 19:15.
At 20:30 Colleague A (midwife) took over the care of Patient O and syntocinon
recommenced, with the approval of the registrar, at 21:10.
Mrs Ratcliffe was the coordinator on night duty.
At 21:30, Mr 9, a midwife, conducted a “fresh eyes” review and the CTG was ‘reassuring’
but at 22:00 a recording in the notes states that there was a deceleration down to 80bpm.
At 22:15 Mrs Ratcliffe conducted a “fresh eyes” review and concluded that the
decelerations on the CTG were due to loss of contact. Mrs Ratcliffe did not enter Patient
O’s room again until shortly before delivery which was at 03:35 when the baby was born in
a poor condition and required ventilation and transfer to SCBU.
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Dr 10 was the registrar responsible for the labour ward from 21:00 on 9 September 2013.
Dr 10 reviewed Patient O at 21:00, 23:00. 23:50, 00:30 and 01:15 when she performed a
Fetal Blood Sampling due to delay and some decelerations and the results were normal.
The doctor relied on Colleague A and Mrs Ratcliffe, as coordinator, to inform her of any
abnormalities.
The next contact, by Dr 10, with Patient O was immediately after the baby was born to
assist with resuscitation. Dr 10 noted on the CTG that there had been a prolonged period
of bradycardia and neither midwife had informed her of the abnormality.
Ms 11 was employed as the Divisional Governance Lead at the material time and was
appointed to investigate the clinical incident with the assistance of Ms 12 who was a
Community Midwife Manager and a Supervisor of Midwives. Ms 11 completed her
management inquiry on 2 December 2013 and Ms 13 completed her supervision report on
2 December 2013. In Ms 12’s recommendation to the LSA, she advised that Mrs Racliffe
should be referred to the NMC.
The panel noted that Ms 12 stated:
“The rationale for this decision is that though Marie has had only one episode of
supervision input in 2010, which was successfully completed, the failings
highlighted in this investigation are so similar to those in the audit of notes in 2009
which led to the 180 hours [Mrs Ratcliffe appears to have completed 180 hours
instead of the recommended 150] supervised practice at the Royal Lancaster
Infirmary it would suggest that Marie has not benefited from this.”
In her statement, Ms 12 highlighted Mrs Ratcliffe’s failings. She stated that Mrs Ratcliffe
failed to support Colleague A. She stated Patient O was a high-risk patient and Ms
Ratcliffe had the responsibility of maintaining an overview of all women on the labour ward
which included identifying risk factors, progress and potential problems in accordance with
Trust’s “Delivery Suite Coordinator Policy 2013. She stated Mrs Ratcliffe failed to check on
Colleague A for five hours and could not have maintained an overview of Patient O’s care
in that period.
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Ms 12 further stated that Mrs Ratcliffe did not seek medical assistance when she entered
Patient O’s room and saw that there had been a lengthy period of time when the fetal
heart rate had been bradycardic. Also, that when Mrs Ratcliffe took over the delivery from
Colleague A she did not write in the notes that she had delivered the baby and the
placenta.
In her report, Ms 11 concluded Mrs Ratcliffe had failed to carry out her role in a number of
areas, namely, the responsibilities of a coordinator, record-keeping and the
misinterpretation of the CTG at the “fresh eyes” review.
In her statement, Ms 11 details the record keeping failures made by Mrs Ratcliffe at the
“fresh eyes” review at 22:15 on 9 September 2013:
• Mrs Ratcliffe documented that Patient O was in spontaneous labour when she had
been induced with prostin and syntocinon;
• Mrs Ratcliffe documented that the CTG recording showed no decelerations when
there are decelerations on the trace at 22:00 and 22:10; and
• Mrs Ratcliffe documented that the trace was normal when it should have been
categorised as suspicious.
Further to the recommendation of Ms 12, Ms 11 concluded that Mrs Radcliffe failed to act
in accordance with Trust policies and guidance relating to documentation and her role as a
coordinator.
In relation to charge 14.1, the panel found that as Mrs Ratcliffe was the co-ordinator on
duty she would have been expected to check on Colleague A at regular intervals.
However, the panel noted Mrs Ratcliffe saw Patient O at 22:15 but then did not go back
and check on her until 03:35. The panel acknowledged that whilst there will be gaps in
time between checks over a night shift, a gap of five hours is unacceptable and not in
accordance with the Trust’s ‘Maternity Unit Bleep Holder/Delivery Suite Coordinator’
guidance. The panel therefore found charge 14.1 proved, in that Mrs Ratcliffe failed to
check Colleague A between 22:15 and 03:20.
In relation charge 14.2, the panel found that, from Ms 12’s statement and Patient O’s
notes, there was evidence that Patient O’s baby was bradycardic and that in light of the
‘Maternity Unit Bleep Holder/Delivery Suite Coordinator’ guidance Mrs Ratcliffe should
have escalated to a medical practitioner ‘in the event of deviation from the norm’. The
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panel found no evidence that Mrs Ratcliffe escalated to a medical practitioner when she
became aware the fetal heart rate was bradycardic. The panel therefore found charge 14.2
proved.
In relation to charges 14.3 (i), (ii) and (iii), based on Patient O’s notes found that Mrs
Raftcliffe had: documented that labour was spontaneous when Patient O’s labour was in
fact induced; documented that there was no declarations on the CTG when the CTG
showed declarations; and categorised the CTG as normal when it was in fact suspicious.
The panel therefore found charges 14.3 (i), (ii) and (iii), proved.
In relation to charge 14.4, the panel, based on Patient O’s notes, found that Mrs Ratcliffe
did not make any records in the delivery by section of Patient O’s notes despite having
delivered the baby. Ms 12 said that although the second midwife had documented the
treatment she had given to Patient O it did not absolve Mrs Ratcliffe of the responsibility of
documenting the care she had given to the patient. The panel therefore found charge 14.4
proved.
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Determination on misconduct and impairment Having announced its finding on all the facts, the panel then moved on to consider firstly
whether the facts found proved amount to misconduct and, if so, secondly whether Mrs
Ratcliffe’s fitness to practise is currently impaired. The NMC has defined fitness to practise
as a registrant’s suitability to remain on the register unrestricted.
The panel also took into account all the oral and documentary evidence adduced in this
case.
The panel took into account the submissions made by Ms Hamilton, on behalf of the NMC.
The panel was provided with Mrs Ratcliffe’s written statement, dated 24 March 2015, and
the Standard Directions Form ‘SDF’ which contained her admissions to all the charges and
that her fitness to practise is impaired.
The panel heard and accepted the advice of the legal assessor.
The panel adopted a two stage process in its consideration as advised. First, the panel
must determine whether the facts found proved amount to misconduct. Secondly, only if
the facts found proved amount to misconduct, the panel must decide whether, in all the
circumstances, Mrs Ratcliffe’s fitness to practise is currently impaired as a result of that
misconduct.
Decision on whether the facts found proved amount to misconduct:
When determining whether the facts found proved amount to misconduct the panel had
regard to the terms of the various versions of the Code in force at that time, namely the
June 2002, August 2004 and May 2008 editions.
The panel in reaching its decision had regard to the public interest and accepted that there
was no burden or standard of proof at this stage and exercised its own professional
judgement.
The panel was of the view that Mrs Ratcliffe’s actions did fall significantly short of the
standards expected of a registered midwife particularly one who is also a registered nurse,
and that her actions did amount to a breach of the code. Specifically;
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The Code of Professional Conduct for Nurses and Midwives, 2002:
As a registered nurse, midwife or health visitor, you are personally accountable
for your practice. In caring for patients and clients, you must:
• respect the patient or client as an individual
• obtain consent before you give any treatment or care
• …
• cooperate with others in the team
• maintain your professional knowledge and competence
• be trustworthy
• act to identify and minimise risk to patients and clients
1.4 You have a duty of care to your patients and clients, who are entitled to receive
safe and competent care.
The code: Standards of conduct, performance and ethics for nurses and midwives, 2008
of the code:
The people in your care must be able to trust you with their health and wellbeing
To justify that trust, you must:
• make the care of people your first concern, treating them as individuals and
respecting their dignity
• work with others to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider community
• provide a high standard of practice and care at all times
• be open and honest, act with integrity and uphold the reputation of your profession.
As a professional, you are personally accountable for actions and omissions in
your practice, and must always be able to justify your decisions.
The panel appreciated that breaches of the code do not automatically result in a finding of
misconduct.
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In relation to charge 1, the panel determined that Mrs Ratcliffe’s actions in failing to
adequately monitor, record observations and recognise a high risk patient which
contributed to the death of Baby B was serious misconduct.
In addition, the panel determined that for Mrs Ratcliffe, immediately after delivery, to place
Baby B next to Patient A, when Baby B was ‘purple and blue in colour’ and ‘looked as
though she had died’ causing Patient A distress was serious misconduct.
In relation to charge 2, the panel determined that for Mrs Ratcliffe, some 4 years later
repeated the same serious failings, such as failing to recognise a high risk patient, failing
to adequately monitor and failing to record observations of the high risk patient. These
actions contributed to the death of Baby C and were serious misconduct.
In addition, to either mislead Patient B or, at its very lowest, not read Patient B’s notes in
relation to the availability of an epidural when Patient B was in pain and had previously
requested it, was serious misconduct.
In relation to charges 3 to 14, the panel determined that on a random sample of eleven
patient’s notes, both Ms 14 and Ms 15 found failings of midwifery care in every single
case.
The panel determined that Mrs Ratcliffe’s misconduct lay at her failings in: record keeping;
monitoring and observing patients; requesting assistance from other suitability qualified
medical professions; supervising colleagues; categorising patients as normal instead of
high risk; and her care of two patients, which contributed to the deaths of Baby B and
Baby C.
The panel is of the view that Mrs Ratcliffe’s failings were numerous which involved 14
patients and 68 proved charges. The failings were wide-ranging and repeated over a ten
year period. Further, Mrs Ratcliffe’s failings were serious in that they contributed to the
deaths of Baby B and Baby C.
Mrs Ratcliffe’s misconduct represented fundamental failings in care of women and their
babies.
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The panel found that Mrs Ratcliffe’s actions did fall seriously short of the conduct and
standards expected of a midwife and amounted to misconduct.
Decision on impairment The panel next went on to decide whether as a result of this misconduct Mrs Ratcliffe’s
fitness to practise is currently impaired.
The panel bore in mind the approach in the fifth Shipman Report which was adopted by
Mrs Justice Cox in CHRE v NMC and Grant [2011] EWHC 927 (Admin):
“Do our findings of fact in respect of the doctor’s misconduct, deficient professional
performance, adverse health, conviction, caution or determination show that his/her
fitness to practise is impaired in the sense that s/he:
a. has in the past acted and/or is liable in the future to act so as to put a
patient or patients at unwarranted risk of harm; and/or
b. has in the past brought and/or is liable in the future to bring the medical
profession into disrepute; and/or
c. has in the past breached and/or is liable in the future to breach one of the
fundamental tenets of the medical profession; and/or
d. …”
It also had regard to paragraph 74 of that judgment, which states;
74. In determining whether a practitioner’s fitness to practise is impaired by reason of
misconduct, the relevant panel should generally consider not only whether the practitioner
continues to present a risk to members of the public in his or her current role, but also
whether the need to uphold proper professional standards and public confidence in the
profession would be undermined if a finding of impairment were not made in the particular
circumstances.
Regarding insight, the panel noted that the gravity of Mrs Ratcliffe’s misconduct was
demonstrated over a decade of serious failings relating to fourteen separate patients. The
panel determined that some of Mrs Ratcliffe’s failings contributed to the deaths of Baby B
and Baby C.
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The panel accepted that Mrs Ratcliffe has demonstrated some remorse in her letter to the
NMC dated, 24 March 2015.
Mrs Ratcliffe stated without elaboration:
‘I accept that I have made mistakes and I apologise to those affected by them. I will
regret what happened for the rest of my life…I seek no leniency or mitigation. They
are statement of my acceptance of those things I cannot change.’
However, the panel can only give limited weight to her statement when considering what
insight Mrs Ratcliffe has had into her actions.
The panel is of the view that Mrs Ratcliffe has sought to distant herself from her own
culpability. She stated, in the letter dated 24 March 2015, that she agrees with the
statement from the Kirkup Report (which the panel has not read) that it ‘makes no criticism
of staff for individual errors which, for the most part, happen despite their best efforts and
are found in all healthcare systems.’
Further, Mrs Ratcliffe stated:
‘I recognise that those monitoring, supervisory and regulatory systems have
subsequently been found to be inadequate and flawed, but I was subject to them
as they were then. I had no control over them…’
Patient A told the panel that at the inquest into the death of Baby B, held in 2013, Mrs
Ratcliffe was asked by the coroner if she would act differently if she was treating a patient
in Patient A’s condition again. Mrs Ratcliffe’s response was that she would not do anything
differently.
The panel is of the view that Mrs Ratcliffe has not reflected on the impact her actions had
on her patients, nor the impact of her misconduct on public confidence and trust in the
midwifery profession. Whilst Mrs Ratcliffe had apologised in writing, the panel has seen
therein limited evidence of remorse and no evidence of insight.
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The panel went on to consider whether Mrs Ratcliffe’s misconduct is remediable, whether
it has been remedied, and whether there is a risk of repetition.
The panel is of the view that the numerous and serious failings would be difficult but not
impossible to remediate. Of greater concern to the panel is Mrs Ratcliffe’s attitude to some
of the patients, their babies and their families since 2004. In these matters before the
panel, she demonstrated an uncaring and unempathetic approach to these patients, a
cavalier approach to monitoring the vitals of patients and unborn babies, a laissez-faire
approach to recording the information that would have assisted her colleagues in caring
for her patients, and a reckless approach in her use of the ‘ARM procedure’ and the
‘Wood-Screw manoeuvre’.
A good demonstration of this attitude is when she told Patient B:
“If only everyone who wanted a caesarean section got one on a whimper.”
The panel is of the view that it is this attitude that underpinned her failings.
The panel was told that Mrs Ratcliffe underwent 180 hours of supervised practice and
successfully completed this in June to September 2010. She repeated it with ‘flying
colours’. This is further evidence that the problem lies with Mrs Ratcliffe’s attitude not her
lack of ability because in 2013 she repeated the same failings with Patient O.
The panel has been provided with no evidence of remedial steps such a piece reflecting
on the seriousness and consequences of her actions. In light of the absence of such
evidence of remedial action, the panel finds that Mrs Ratcliffe’s misconduct has not been
remedied.
In those circumstances the panel is of the view that if Mrs Ratcliffe is placed in similar
situations, as she faced in the charges, there is a very high likelihood she would repeat her
misconduct. In the panel’s judgement there is a real risk of repetition of her misconduct
and the panel is satisfied that, should she be allowed to practise unrestricted, patients
would be put at risk of harm.
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The panel has borne in mind that its primary function is to protect patients and the wider
public interest, which includes maintaining confidence in the midwifery profession and
upholding proper standards and behaviour.
Midwives occupy a position of privilege and trust in society and are expected at all times to
be professional. Patients and their families must be able to trust midwives with their lives
and the lives of their unborn babies. To justify that trust, midwives must act with integrity.
They must make sure that their conduct at all times justifies both their patients’ and the
public’s trust in the profession.
The panel is of the view that Mrs Ratcliffe’s poor care, on the occasions in the charges
found proved, not only put patients at a risk of harm but caused actual harm to patients
entrusted in her care, including contributing to the deaths of Baby B and Baby C. Mrs
Ratcliffe’s actions breached the fundamental professional tenets of the profession, that is
provide a high standard of care at all times. Further, the panel determined that Mrs
Ratcliffe’s actions brought the profession into disrepute.
The panel is satisfied, based on all the evidence, that should Mrs Ratcliffe be in a similar
situation again there is a very real risk that she will once more act in breach of those
principles, put her patients at risk of harm and bring the profession into disrepute.
Further, the panel is of the view that the seriousness of these matters and the lack of any
meaningful insight that has been demonstrated meant that in the circumstances of this
case public confidence in the profession and the regulatory process would be undermined
if a finding of impairment were not made.
The panel makes it clear that it does not assert that Mrs Ratcliffe bears sole responsibility
for the poor standard of care received by these patients from the Hospital.
Her conduct should been seen against a background of other organisational and individual
failure, evidence of which has been before the panel at these proceedings.
Having regard to all of these considerations, the panel is satisfied that Mrs Ratcliffe’s
fitness to practise is currently impaired.
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Decision on sanction and reasons: The panel has considered this case very carefully and has decided to make a striking-off
order. The effect of this order is that the NMC register will show that Mrs Ratcliffe’s name
has been struck from the register.
In reaching this decision the panel has had regard to all the evidence that has been
adduced in this case. The panel accepted the advice of the legal assessor. The panel has
borne in mind that any sanction imposed must be reasonable, appropriate and
proportionate, and although not intended to be punitive, its effect may have such
consequences. The panel had careful regard to the Indicative Sanctions Guidance
published by the NMC. It recognised that the decision on sanction is a matter for the panel
exercising its own independent judgement.
The panel considered all the mitigating and aggravating factors in this case.
The panel considered the aggravating factors:
• Wide spectrum of failings over a protracted period;
• Repetition of failures despite successfully completion of 180 hours of supervised
practice;
• Minimised her responsibility in her response to the charges;
• Deep-seat attitudinal behaviour manifesting in practice;
• Failing to take responsibility for her actions and attempting to blame other
colleagues;
• Patient A and Patient B both stated that they lacked trust in Mrs Ratcliffe; and
• Patient B was a nervous and anxious patient who was not given the pain relief of
her choice which was an epidural.
The panel considered the mitigating factors:
• Long career with a high rate of delivering babies;
• Successfully completed 180 hours supervised practice;
• Admitted all the factual charges and that her fitness to practise was impaired and
thereby minimising delay and prolonging these proceedings; and
• Worked within a culture of other organisational and individual failure.
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The panel first considered whether to take no action but concluded that this would be
inappropriate in view of the seriousness of the case. The panel decided that it would be
neither proportionate nor in the public interest to take no further action.
The panel next considered whether to place a caution order on Mrs Ratcliffe’s registration
but concluded that this would be inappropriate in view of the seriousness of the case. This
would be utterly inappropriate. The panel decided that it would be neither proportionate
nor in the public interest to impose a caution order.
The panel next considered whether placing conditions of practice on Mrs Ratcliffe’s
registration would be a sufficient and appropriate response. The panel is mindful that any
conditions imposed must be proportionate, measurable and workable. The panel took into
account the Indicative Sanctions Guidance, in particular;
67.8 It is possible to formulate conditions and to make provision as to how
conditions will be monitored
The panel was of the view that Mrs Ratcliffe’s misconduct was in relation to a failing of
basic and fundamental clinical care of patients. Further, the panel found that her failings
are aggravated by attitudinal behaviour. The panel noted that as Mrs Ratcliffe has not
engaged with these proceedings, there is no evidence that Mrs Ratcliffe would be willing to
undertake retraining or supervised practice. The panel determined that Mrs Ratcliffe would
not benefit from retraining and proper supervision, as she had already undertaken 180
hours of supervised practice but continued to repeat her misconduct.
The panel is of the view that retraining and supervised practice would not adequately
address the seriousness of this case and nor would it protect the public. Consequently, the
panel determined that a conditions of practice order would neither be appropriate nor
sufficient in this case.
The panel then went on to consider whether a suspension order would be an appropriate
sanction. Paragraph 71 of the ISG indicates that a suspension order would be appropriate
where (but not limited to):
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71.2 The misconduct is not fundamentally incompatible with continuing to be a
registered nurse or midwife in that the public interest can be satisfied by a
less severe outcome than permanent removal from the register.
71.3 No evidence of harmful deep-seated personality or attitudinal problems.
71.5 The panel is satisfied that the nurse or midwife has insight and does not pose
a significant risk of repeating behaviour.
The panel has already considered that the care given to Patient A and Patient B which
contributed to the deaths of Baby B and Baby C was serious misconduct. Further, that Mrs
Ratcliffe has not only demonstrated no insight into her failings but has demonstrated an
attitudinal problem in that, she said, if faced with a similar situation again she would not act
differently. The panel determined that by Mrs Ratcliffe attempting to distance herself from
her own failings, no period of suspension would be sufficient to allow her to reflect on her
actions which would enable her to return to safe practice.
In addition, the panel has borne in mind that Mrs Ratcliffe’s failings were repeated over a
10 year period. In that period, Mrs Ratcliffe successfully completed 180 of supervised
practice. Despite this period of supervision, Mrs Ratcliffe repeated her failings.
The panel has already found that Mrs Ratcliffe’s failings are serious, wide ranging,
involving vulnerable patients in her care. Further, that her misconduct was a significant
departure from the standards expected of registered midwife.
Bearing in mind the seriousness of Mrs Ratcliffe’s conduct, her persistent lack of insight
into her actions, the absence of any remediation, and what the panel views as her harmful
and deep-seated attitudinal problem, the panel is of the view that a suspension order
would not be an appropriate or proportionate sanction.
Mrs Ratcliffe’s conduct, as highlighted by the facts found proved, was a very significant
departure from the standards expected of a registered midwife. In the panel’s judgement it
can be said that the serious breaches of the fundamental professional principles of care
lacking in Mrs Ratcliffe’s actions are fundamentally incompatible with her remaining on the
register.
In considering whether to make a Striking-off Order the panel took note of the following
paragraphs of the Indicative Sanctions Guidance:
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74.1 Is striking-off the only sanction which will be sufficient to protect the public
interest?
74.2 Is the seriousness of the case incompatible with ongoing registration.
74.3 Can public confidence in the professions and the NMC be sustained if the nurse
or midwife is not removed from the register?
75.2 Doing harm to others or behaving in such a way that could foreseeably result in harm to others, particularly patients or other people the nurse or midwife comes into contact with in a professional capacity, either deliberately, recklessly, negligently or through incompetence, particularly where there is a continuing risk to patients. Harm may include physical, emotional and financial harm.
75.3 Abuse of position, abuse of trust, or violation of the rights of patients, particularly in relation to vulnerable patients
75.7 Persistent lack of insight into seriousness of actions or consequences
Mrs Ratcliffe’s contribution to Baby B and Baby C’s deaths was a serious departure from
the standards expected of a registered midwife. The panel is of the view that her persistent
and repeated failures in care along with her lack of insight into their consequences are
demonstrative of a deep seated attitudinal problem.
In reaching its decision the panel has kept in mind that there are nonetheless mitigating
factors that stand in Mrs Ratcliffe’s favour and which the panel has set out earlier in this
determination. It has borne in mind the potential impact which a striking off order will have
on Mrs Ratcliffe. However, balancing all of these factors and taking into account all of the
evidence in this case, the panel has determined that the only appropriate and
proportionate sanction is a Striking-Off Order.
In the panel’s judgement her conduct has fundamentally breached public trust in the
profession, and is fundamentally incompatible with her remaining on the register. The
panel is satisfied that this is the only sanction which will be sufficient to protect the public
interest and to maintain confidence in the profession and the regulatory process. It has
concluded that nothing short of this would be sufficient in this case.
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Decision on Interim Order and reasons: The panel has considered the submissions made by Ms Hamilton that an interim order
should be made on the grounds that it is necessary for the protection of the public and
otherwise in the public interest.
The panel accepted the advice of the legal assessor.
The panel was satisfied that an interim suspension order was necessary for the protection
of the public and otherwise in the public interest. The panel had regard to the seriousness
of the facts found proved and the reasons set out in its decision for the substantive order
in reaching the decision to impose an interim order. To do otherwise would be
incompatible with its earlier findings.
The period of this order is for 18 months to allow for the possibility of an appeal to be
made and determined.
If no appeal is made then the interim order will be replaced by the striking-off order 28
days after Mrs Ratcliffe is sent the decision of this hearing in writing.
That concludes this determination.