A mother has said she will suffer with PTSD for the rest of her life after the loss of her daughter.
It comes as her two midwives – Lisa Land and Hazel Williams – were struck off for the deaths of her baby Margot and a boy born eleven months prior.
Laura Bowtell said she had trusted award-winning midwife Ms Land and felt ‘at ease’ in her hands when she and her partner Craig arrived at the Cheltenham Birth Centre in May 2020.
The midwife was very ‘chilled’, telling Mrs Bowtell she was ‘low risk’ and everything was normal, despite there being several red flags.
After six hours in labour, the pregnant mother was ‘exhausted’ and asked Ms Land to call an ambulance for her – but the midwife wanted to use ‘oils’ and different positions instead.
It was only after asking for a third time Ms Land relented and called an ambulance, but by that time baby Margot’s heart rate had dropped.
Three days later, her life support was withdrawn and the couple drove home with an empty baby seat in the back of their car.
Mrs Bowtell, 37, told that if Ms Land had listened to her, she wouldn’t have had to go through the traumatic loss of her first pregnancy. She said: ‘Margot would still be here and I wouldn’t have to live with this for the rest of our lives.’
Ms Land and another midwife Ms Williams have since been thrown out of the profession following the deaths of and Margot another newborn, Jasper White.
Both babies were seriously ill when they were born at the Aveta Birth Centre in Cheltenham, Gloucestershire.
The midwives failed to call the ambulance soon enough in both cases, which had tragic consequences.
The pair altered medical records to make it appear like Jasper – who was struggling to breathe and was a ‘pale colour’ – was in a better condition than he was.
They were hauled in front of a Nursing and Midwifery Council (NMC) committee for not providing ‘basic midwifery care’ and dishonesty and were struck off.
Mrs Bowtell – who used to work in aviation – now has a 10-month-old daughter who she had via C-section.
But she said the ‘PTSD I have will stay with me for the rest of my life’.
She often looks at her friends’ children who are a similar age to what Margot would be today and wonders what could have been.
Her partner Craig is in the military, and he was away in Norway for the last nine weeks of her pregnancy, but Ms Land was there for her throughout.
Mrs Bowtell told : ‘It was my first pregnancy so you don’t know what to expect. I completely put my trust in the midwives. She was very chilled, she kept telling me I was low risk.
‘They told me I would be transferred if I needed it and she was very confident in her ability to spot when that would be needed. When I went into labour at midnight, Lisa was on the night shift and I felt at ease. She was the main person throughout.
‘She arrived and I couldn’t keep anything down, I was running on empty. My contractions weren’t giving me enough to push. She assumed all of this was normal.
‘She should have transferred me to Gloucester. I first asked for an ambulance at 10am, I was exhausted. But she wanted to try lots of oils and things instead.’
In the weeks leading up to the birth, Mrs Bowtell had a minor haemorrhage and reduced foetal movement which should have prompted a risk assessment and her transfer to an obstetric-led unit by Mrs Land.
In the early hours of May 14, during labour, Mrs Bowtell had blood in her amniotic fluid and a low temperature both of which should have prompted Mrs Land to call an ambulance.
She said: ‘I asked [for an ambulance] again and she said ‘let’s do this instead’ and put my legs in stirrups. The third time I asked one came.
‘At this point my labour had progressed and that was when the heart rate dropped.’
Margot’s head was visible and it was too late for the pair to be transferred to the hospital half an hour away before Mrs Bowtell gave birth at 1:30pm.
Margot required immediate resuscitation when she was born and once at hospital, she was taken to the neonatal intensive care unit but, sadly, she passed away three days later due to complications from oxygen deprivation.
During the birth, her foetal heartbeat dropped below 60bpm which should have prompted an emergency response from the whole unit, led by Miss Williams as the lead midwife.
This did not happen Miss Williams used the regular call bell to ask for help and not the emergency bell because it was regularly switched off as she wanted the centre to be a ‘home from home’ without alarms going off.
Miss Williams also did not give a handover to the receiving hospital to alert them to the baby’s low heart rate.
Instead, she handed Mrs Bowtell’s care over to Miss Williams just before 8am who ‘failed’ to fully check the notes made by Mrs Land about the bleeding and also did not escalate treatment.
An internal investigation also revealed that Mrs Land was not aware that a below average temperature is a risk factor for sepsis.
Almost a year later, in March 2021, Mrs Land sent a WhatsApp message to Mrs Bowtell to ask her how she was, in what would usually be a normal move.
But after what she had gone through because of her decisions, Mrs Bowtell said it ‘filled her with anger’.
Mrs Bowtell added: ‘If I had been sent to Gloucester I would have had an emergency C-section. Margot would still be here and I wouldn’t have to live with this for the rest of our lives.
‘The PTSD I have will stay with me for the rest of my life.’
Mrs Bowtell is calling on the Government to ‘step in and do something’ and said the state of midwifery is concerning and dangerous.
She said there is a lack of funding and training, along with a toxic culture which needs to change.
‘Lisa and Hazel were bullying other midwives into not pressing the emergency button,’ she said.
When she found out she was pregnant the second time around, she made sure she ‘changed everything’.
She said: ‘For my 10-month-old daughter I had a planned C-section. My anxiety was through the roof and I couldn’t relax. ‘
Miss Williams and Mrs Land, who have been midwives for 34 and 16 years respectively, have both been struck off the register.
Just a year before, both of the midwives had won Gloucestershire Hospitals’ award for Best Quality Improvement Project for Implementation of a Continuity of Care model at Aveta Birth Unit.
Mrs Bowtell slammed this decision, saying: ‘The fact that they were given an award is a joke. I would like to know what the hospital has to say for themselves about that.
‘Mothers who didn’t want to give birth there because they felt it was unsafe were ignored and they were annoyed at them. How on earth have they got an award?’
She wants to speak about her experience to help other mothers and ‘break the taboo of talking about baby loss’.
‘It feels very isolated’, she said. ‘People told me “Margot just wasn’t meant to live” and that is really insensitive.
‘I want to educate people – sometimes just say “I’m here for you”.
‘It was the worst news in the world.’
An independent investigation by the Healthcare Safety Investigation Branch took place into Margot’s death.
It found that the bleeding in labour meant Mrs Bowtell should have been transferred to Gloucestershire Royal Hospital sooner and it could have saved Margot.
Eleven months before, the same two midwives who delivered Margot had also not called an ambulance soon enough for another newborn, Jasper.
On June 25, 2019, baby Jasper was born at the clinic, within minutes he was struggling to breathe.
However, an ambulance was not called until 50 minutes after his birth, including a 20-minute delay between Mrs Land deciding that he needed to be transferred and the emergency call being made.
It was not until an hour and a half after his birth that Jasper was officially transferred to the neonatal unit. He sadly passed away there the next morning from a lack of oxygen and a haemorrhage.
An expert witness told a tribunal panel that the delay ‘significantly shortened’ the chances of Jasper surviving, she said it was not certain he would have lived but the cause of his deterioration might have been reversed if he had been transferred to the neonatal unit faster.
She said Miss Williams should have ‘escalated’ Jasper’s treatment as soon as she realised he was struggling, just a few minutes after his birth.
The hearing was told that after Jasper’s death, Miss Williams told Mrs Land to change the ‘details of birth’ form from recording Jasper’s condition as ‘poor’ to ‘good’.
Miss Williams also made changes to other statistics on the record to make it seem like Jasper was in better health than he was.
The panel concluded it was ‘dishonest’ for the two women to make these changes and that they intended to ‘mislead’ anyone who checked the records.
Striking off the two midwives, the panel said they had ‘breached fundamental tenets’ of midwifery and their actions could discourage the public from seeking services at a birthing unit.
They said: ‘[Their] misconduct has breached fundamental tenets of the midwifery profession, particularly in relation to not transferring Baby A or Patient B which the panel considered to be fundamental basic midwifery care.
‘Further, the panel considered [their] attempt to cover up [their] actions with inaccurate and dishonest record keeping to be a breach of the fundamental tenets of the midwifery profession and therefore brought its reputation into disrepute.
‘It was of the view that such acts or omissions could discourage members of the public to seek midwifery services at a birthing unit.’