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Berkshire midwife reported to regulator over baby's death Berkshire midwife reported to regulator over baby's death
(2 months later)
Royal Berkshire Hospital did not immediately report the midwife, the coroner saidRoyal Berkshire Hospital did not immediately report the midwife, the coroner said
Royal Berkshire Hospital did not immediately report the midwife, the coroner saidRoyal Berkshire Hospital did not immediately report the midwife, the coroner said
An agency midwife has been reported to the nursing regulator after a coroner raised concerns over a baby's death.An agency midwife has been reported to the nursing regulator after a coroner raised concerns over a baby's death.
Raniya Khan died in May 2020, 19 days after she was born at Royal Berkshire Hospital, Reading.Raniya Khan died in May 2020, 19 days after she was born at Royal Berkshire Hospital, Reading.
Senior Berkshire Coroner Heidi Connor said the labour was not properly monitored, although the failures may not have caused the death.Senior Berkshire Coroner Heidi Connor said the labour was not properly monitored, although the failures may not have caused the death.
The hospital said it complied with the coroner's instruction to refer the case to the Nursing and Midwifery Council.The hospital said it complied with the coroner's instruction to refer the case to the Nursing and Midwifery Council.
In a Prevention of Future Deaths Report, external, Mrs Connor said the band 6 midwife, who she did not name, failed to recognise signs of ill health on the fetal trace.In a Prevention of Future Deaths Report, external, Mrs Connor said the band 6 midwife, who she did not name, failed to recognise signs of ill health on the fetal trace.
She also did not conduct proper reviews, mistook the maternal heart rate for the baby's and did nothing about the mother's high pulse rate, Mrs Connor said.She also did not conduct proper reviews, mistook the maternal heart rate for the baby's and did nothing about the mother's high pulse rate, Mrs Connor said.
Raniya Khan died on 28 May 2020 from the effects of severe arterial pulmonary hypertension - high blood affecting the lungs - of unknown cause, the coroner concluded.Raniya Khan died on 28 May 2020 from the effects of severe arterial pulmonary hypertension - high blood affecting the lungs - of unknown cause, the coroner concluded.
Mrs Connor said she discovered during the inquest that the hospital had not reported the case.Mrs Connor said she discovered during the inquest that the hospital had not reported the case.
She said: "The trust should refer concerns about this individual agency midwife as a matter of urgency [to] both NHS Professionals and to the Nursing and Midwifery Council.She said: "The trust should refer concerns about this individual agency midwife as a matter of urgency [to] both NHS Professionals and to the Nursing and Midwifery Council.
"This is in addition to raising of the possibility of an individual 'passport' to prevent a midwife moving between agencies to work elsewhere after significant concerns have been raised.""This is in addition to raising of the possibility of an individual 'passport' to prevent a midwife moving between agencies to work elsewhere after significant concerns have been raised."
Royal Berkshire NHS Foundation Trust said it noted the coroner's conclusion that "earlier delivery was unlikely to have changed the outcome".Royal Berkshire NHS Foundation Trust said it noted the coroner's conclusion that "earlier delivery was unlikely to have changed the outcome".
Director of Strategy Andrew Statham said: "As the coroner noted in her report, the trust is very much focused on improving obstetric and midwifery care as evidenced by the increase in staffing and training and changes to the induction of agency staff."Director of Strategy Andrew Statham said: "As the coroner noted in her report, the trust is very much focused on improving obstetric and midwifery care as evidenced by the increase in staffing and training and changes to the induction of agency staff."
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