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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


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


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


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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14.2 Failed to request medical assistance when you became aware that the fetal heart rate was bradycardic;


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



1.8 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.



2.8 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




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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:


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



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




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


12.1 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;





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

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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


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


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)



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




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:


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.


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.


recorded maternal observations. The panel, therefore, found charge 8.4 proved.


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


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



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,


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




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


12.1 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

48

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


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.


Ratcliffe documented a detailed description of the CTG trace in the notes. The panel

therefore found charge 13.3 proved.


Ratcliffe recorded the dosage of syntocinon that was administered to Patient N. The panel

therefore found charge 13.4 proved


Ratcliffe recorded the dosage of ergometrine that was administered to Patient N. The

panel therefore found charge 13.5 proved.

50

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;




51


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.

52

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.

53

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

54

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.

55

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;

56

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.

57

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.

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