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Midwife let down by her own NHS Trust

By Clare Gooch

Midwife, Gemma Bentley and her husband, sadly lost their baby following negligent care provided by the Trust she works within.

babys feet held by mum

In a recent inquest, Gemma Bentley was reported to have had an unremarkable pregnancy with no cause for concern until 13 June 2020. Gemma was admitted to Burnley General Teaching Hospital following scans that demonstrated her unborn baby’s growth had slowed down. However, following a series of miscommunications, a lack of urgency and incorrect classification on foetal monitoring, she sadly lost her son 17 hours after he was born. 

An inquest heard that delays of 6 hours meant that foetal distress was not detected soon enough leading to a significant delay in his delivery. At the point foetal distress was detected via CTG trace, Gemma should have been rushed to theatre for an emergency C-section. However, the concerning CTG trace was not even reported to the on-call for review, leaving Gemma and her unborn son at significant risk. Consequently, due to a lack of communication about the severity of the situation, Gemma’s transfer to the birthing suite took 39 precious minutes and thereafter a further hour for Gemma’s son to be delivered.

At inquest, the coroner heard that this all could have been avoided. He also heard that Gemma was unaware of how serious the situation was due to potential ‘unconscious bias’ due to the fact that she worked within the maternity unit.

The East Lancashire Hospitals NHS Trust, following investigation by HSIB, has taken full responsibility for what has happened to Gemma and her family but sadly this does not rectify the mistakes that were made, which ultimately led to the loss of her son. 

We act for so many families who have suffered as a result of poor maternity care. Babies have died or been brain damaged , parents have suffered trauma and mothers have suffered obstetric injury

We encourage anyone who has been affected by care received from East Lancashire Hospitals NHS Trust to make  contact with us so that we can begin to support you too. Call 0800 138 0458 or email

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Clare has worked in Medical Negligence for over 10 years.  She’s a Senior Associate Solicitor in our Medical Negligence team based in Switalskis’ London office.

Senior Associate Solicitor

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