Charge

A professional Conduct Committee (PCC) charged that the Midwife (name suppressed) was guilty of professional misconduct.  The particulars of the Charge were as follows:

1. That during the period November 2006 – January 2007 when acting in the role of midwife for her seventeen year old client, (Ms S),  the Midwife failed to act at all times in the best interests of her client:
   1. While continuing to act in her role as Ms S’s midwife the Midwife initiated promoted progressed and managed a private adoption with the Midwife’s daughter and son-in-law, (Mr and Mrs R), as the prospective adoptive parents.
   2. In continuing to act as Ms S’s midwife when at the same time promoting progressing and managing a private adoption with her daughter and son-in-law as the prospective parents the Midwife:
      1. promoted her own personal interests including but not exclusively that as a prospective adoptive grandparent.
      2. Failed to advise and/or make Ms S aware of the mandatory statutory pathways for adoptions.
      3. Failed to respond to Ms S’s social psychological and emotional needs.
      4. Caused harm to Ms S.
      5. Acted in breach of the Competency for Entry to the Register of Midwives, the College of Midwives Standards of Practice and the Code of Ethics.
2. The Midwife failed to document or adequately document:
   1. Conversations of significance that she had with Ms S’s social workers.
   2. Ms S’s feelings and views.
   3. Ms S’s social and family situation.
   4. Ms S’s thoughts and intentions about the private adoption process.
   5. Discussion and/or consideration of other potential options for Ms S.
   6. Any discussions she had with Ms S about her continuing to be Ms S’s midwife at a time that she  promoting progressing and managing the adoption to her daughter and son-in-law.
   7. Her observations and/or interactions with Ms S concerning her psychological and emotional wellbeing.
   8. Decisions made and midwifery care offered and provided by her.
   9. Her professional actions and the reasons for them.

Finding

The Tribunal found the Midwife guilty of professional misconduct.

Background

On 20 November 2006, the Midwife saw Ms S professionally for the first time.  Ms S was about 34-35 weeks pregnant.  She was aged 17, undertaking exams, and the possibility of adoption was under active consideration by her family.

The Midwife contacted her own daughter to see whether she and her husband (Mr and Mrs R) wished to be considered for adoption.  They did, and forwarded a profile relating to themselves to the Midwife; who gave that to Ms S, Ms S’s mother and Ms S’s step father on 24 November 2006.

From about 23 November 2006 other professionals started to become involved; a solicitor acting for Ms S, a medical social worker, and two social workers from the Adoptions Unit of the Child Youth and Family Services (CYF).  There was no contact between Ms S and the Adoptions Unit until 14 December 2006.  Until this time, Ms S was solely considering Mr and Mrs R as candidates for a “private” adoption.  After she contacted the CYF social worker, profiles for other adoption candidates were sent to her. 

The solicitor acting for Ms S became concerned that the Midwife had a conflict of interest. The solicitor wrote a letter to Ms S on 14 December, raising concerns as to whether the Midwife could be impartial, and suggesting another midwife should be considered.  This letter was discussed by Ms S with the Midwife.  They explored the possibility of another midwife to attend Ms S at the time of delivery.

Subsequently, a medical social worker wrote a letter directly to the Midwife, raising the same issues.  The letter was received by the Midwife as Ms S went into labour, on 29 December 2006.  An alternative midwife was not immediately available that night. The Midwife attended to the delivery, having first asked Ms S to sign the notes approving that step.

On 2 January 2007, Ms S left her baby at the hospital, apparently in anticipation of adoption.  However, it was evident from the hospital notes that she was very distressed when considering the adoption option.  On 5 January 2007, she rang a CYF social worker, and explained that she was thinking of keeping the baby.

The social worker met with her and family members.  The necessary arrangements were then made for Ms S and the natural father Mr D to take their baby to the home of Mr D’s sister, with the intention – which was implemented – of bringing the baby up themselves.

Reason for Finding

The Tribunal considered Ms S was in a very vulnerable position for the following reasons:

• She was aged only 17.
• She had apparently spent up to 30 weeks not knowing she was pregnant.
• She had been sitting night school exams.
• The father of the child had initially terminated their relationship when he found out about the pregnancy and was threatening to raise guardianship issues.
• Her stepfather was opposed to her taking the baby home, and it appeared her mother was supporting him in that regard.

Subparticular 1.1:

The Tribunal found that the steps taken by the Midwife with regard to her daughter and son-in-law were active, consistent and ongoing.

On the basis of the evidence presented, the Tribunal considered the Midwife clearly initiated, promoted and progressed the intended adoption with her daughter and son-in-law; and in a wide sense “managed” or oversaw that process. There was a definite plan (as recorded from 4 December) until the time of birth.  In a general sense she managed that by keeping in touch with the various participants – particularly Ms S and her family, and Mr and Mrs R, but also the social workers and Ms S’s lawyer.  The Tribunal was completely satisfied that this subparticular was established.

Subparticular 1.2.1:

The Tribunal was not satisfied that in initiating, promoting and progressing the adoption to the Midwife’s daughter and son-in-law, she was attempting to advance her own interests as a prospective adoptive grandparent.  She wanted to help her daughter and son-in-law; it was their interests she was promoting, rather than her own.  This subparticular was not established.

Subparticular 1.2.2

The particular appeared to allege that the Midwife did not comply with her obligations to inform Ms S of the role of the social workers from the Adoption Unit of CYF.  Her clear evidence, however, was that she did tell Ms S to contact the CYF social worker.  The Tribunal was not satisfied this particular was established.

Subparticular 1.2.3:

The Tribunal considered this allegation related to one of the central problems which occurred in this case.  The Tribunal considered Ms S was very vulnerable and had limited support.  A critical part of the care of which a midwife must give to a mother antenataly and postnately includes her “wellbeing”.

An aspect of a mother’s psychological wellbeing is her ability to make a fully informed decision about the future of her baby, uninfluenced by any pressures from her midwife. 

The Tribunal found the Midwife did not have sufficient insight into the very difficult dynamics with which Ms S had to cope.  She was supposed to be one of the key supports for a very young mother undergoing a traumatic experience.  The Tribunal was satisfied that by involving herself so actively in the proposed adoption to her own daughter and son-in-law, there was a failure to give sufficient regard to Ms S’s social, psychological and emotional needs.

This subparticular was well established.

Subparticular 1.2.4:

In the Tribunal’s view, there were a number of consequences of the situation which occurred in this case, which can properly be described as having caused “harm” to Ms S.

There was no truly independent midwife supporting Ms S in the various options which she had to consider in a very difficult personal situation; because the Midwife was so closely identified with a particular choice (adoption to Mr and Mrs R).  Ms S did not have the opportunity to discuss her choices in a frank way with her midwife.  Therefore, the prospect of her being able to reach a fully informed decision as to the future of her baby was compromised.

A further element of the harm that was caused was that the introduction to Mr and Mrs R was premature.  The evidence clearly established that at the time of introduction they had not been approved by CYF as prospective adoptive parents.  There was a risk that they might be declined causing further upset.

In addition, not only was Ms S herself encouraged by the Midwife to believe that adoption to Mr and Mrs R was a good idea, but others who were particularly close to Ms S (particularly her mother and stepfather) were as well.  This would have impacted on Ms S.

At the time of delivery, there was apparently discussion between the Midwife and Ms S as to whether the Midwife would undertake the delivery.  It was agreed the Midwife would have to be the attending midwife, and Ms S was required to sign the notes.  The Tribunal considered that it was very regrettable that this issue had not been resolved adequately prior to the delivery, and that this young mother was confronted with having to make such a difficult decision when in the very throes of childbirth.

Ms S was discharged on 2 January 2007, pursuant to a plan that the baby would be adopted – about which she was unhappy and uncertain – and thus separated from her baby.  This was a crucial stage for the attachment of an infant to her mother, and this was yet a further example of the harm which was caused.

The Tribunal was completely satisfied that this subparticular was established.

Subparticular 1.2.5

The Tribunal was satisfied that the Midwife did not uphold the significant responsibilities she had to Ms S to ensure her right to a free informed choice and consent throughout her childbirth experience.  The Tribunal was well satisfied that this subparticular is established.

Particular 2:

The Tribunal was satisfied that proper record keeping is a cornerstone of good midwifery practice.  The difficulties which arose in this case were that very little of Ms S’s circumstances, other than data relating to Ms S’s physical health, were recorded by the Midwife.

Subparticular 2.1

There were three social workers with whom the Midwife had telephone conversations.  No single record was made by her in respect of any of those conversations.  The Tribunal was of the view these conversations were important.  They clearly related to the patient’s wellbeing, social, emotional and psychological circumstances, and needed to be recorded.  The subparticular was established.

Subparticular 2.2:

There was some reference in the midwifery notes to Ms S’s views.  However, these were not adequately recorded.  This subparticular was established.

Subparticular 2.3: Ms S’s social and family situation:

No information was recorded as to:

• Ms S’s home situation and the significant pressure she was under.
• The nature of her relationship with the natural father.
• The fact that she was undertaking exams at night school.
• The absence of income.

The Tribunal was satisfied they were relevant to proper understanding of Ms S’s wellbeing.  This subparticular was established.

Subparticular 2.4:

There were no notes, in particular, of Ms S’s real views as to the pros and cons of adoption, or other options she might consider.  This subparticular was established.

Subparticular 2.5:

The Midwife stated there was a discussion and some exploration of an alternative midwife was undertaken.  None of this appeared in the notes and neither was there any indication in the notes of other possible options being discussed with Ms S, such as delivery being undertaken at another facility.  The Midwife’s case proceeded on the basis that this would have required Ms S to move out of the particular region.  However, the Tribunal was of the view that was an option which should have been put to Ms S, and the pros and cons properly discussed.  This subparticular was established.

Subparticular 2.6 - 2.9

The Tribunal considered that on the facts these subparticulars were established.

Summary

The Tribunal was satisfied that considered separately particular 1 and particular 2 both individually constituted professional misconduct. The charge required the Tribunal to consider the established particulars cumulatively. As they individually amounted to professional misconduct, it followed that cumulatively they amounted to professional misconduct. 

Penalty

The Tribunal made the following orders

• Supervision was ordered for a period of 18 months from 1 April 2009.  The supervisor was to be approved by the Midwifery Council.  The supervisor was to meet the Midwife at least once per month, and to report to the Midwifery Council as may be required by it.  There was to be no mentoring of any midwife during the period of supervision.  The cost of supervision was to be met by the Midwife.
• The Midwife was ordered to undertake a technical skills workshop with the Midwifery Council within six months.
• The Midwife was censured and ordered to pay 40% of the costs of the Tribunal and the PCC.

The Tribunal recommended to the Midwifery Council that a standards review be conducted annually on the Midwife for the next three years.