Baby Joseph’s heart trace ‘was misinterpreted’

It found the root cause of baby Joseph’s “unexpected” stillbirth was a misinterpretation of his heart trace and the failure to perform a blood test on him at the appropriate time.

It did not attribute blame but singled out a number of factors among them the inexperience of the junior doctor, a registrar, on duty from 1pm. It also said the consultant in charge, Catherine Reiss, was “involved in organisational issues not relating to on-call duties”.

It found a blood sample should have been taken from Joseph as early as 12.30pm to see if he was in distress and that half an hour later an assisted delivery could have been considered. Instead Mrs Steel was told to continue pushing. Joseph was delivered only at 3.20pm after an emergency caesarian.

Among five recommendations, it said in future another midwife or doctor should review a heart trace every two hours. Consultants were to have no other commitments on the labour suite and also to “ensure a physical round is undertaken for high-risk cases”.

Following a complaint from the Steels, the General Medical Council commissioned an expert report it said made a “number of highly critical comments” about the care provided.

In her response, it said the registrar claimed her treatment had been appropriate and that she was planning to take a blood sample when she was directed otherwise by Dr Reiss. Dr Reiss said she was involved with another patient and had asked the registrar to assess Mrs Steel. She said the baby appeared deliverable based on the information given to her and she had not been asked to review the patient or the heart trace.

The GMC last year decided to hold a fitness to practise hearing for both doctors. But this month it said it was applying to cancel it because, after considering case law and the fact there were no other concerns about the doctors, it did not believe there was a realistic prospect of their fitness to practise being currently impaired.