Baby died of brain injury after midwives ‘neglected’ mum while breastfeeding

Reflection

1. Why might this have happened? Possible causes (link to current issues in H&SC)
2. What could have been done to prevent this?

Please answer the reflection questions in detail. You should give detail to your answers and link them
to topics covered in H&SC e.g. Unit 5 and 2.

1. Failure to follow safe breastfeeding guidelines: The midwives breached established guidelines by
allowing the mother to breastfeed while she was under the influence of gas and air. These guidelines
exist to ensure the safety and well-being of both the mother and the baby during breastfeeding.

Lack of awareness or training: The student midwife involved in the incident placed a pillow under the
mother's arm, which is contrary to accepted practice. This suggests a lack of proper training or
awareness of the appropriate procedures. Adequate education and training are crucial for healthcare
professionals to ensure they follow established guidelines and provide safe care.

poor supervision: The fact that the midwives did not respond appropriately to the mother's concerns
about her baby's breathing indicates a failure in supervision and monitoring. It is essential for
healthcare professionals to be attentive to patients' needs and promptly address any signs of distress
or discomfort.

2. Comprehensive training and education: Healthcare professionals should receive thorough training
on safe breastfeeding practices, including the importance of adhering to guidelines. Regular updates
and refresher courses can help reinforce these practices and ensure healthcare providers are up to
date with the latest recommendations.

Clear communication and teamwork: Effective communication among the healthcare team is crucial
to ensure everyone is aware of the patient's needs and any potential risks. Encouraging a culture of
open communication and teamwork can help identify and address issues promptly.

Adequate staffing levels: Having an appropriate number of skilled staff available can help prevent
neglect and ensure that patients receive the necessary care and attention. Overburdened staff may
struggle to provide adequate supervision and monitoring, increasing the risk of adverse events.

Regular sessions and quality improvement initiatives: Conducting regular audits and quality
improvement initiatives within healthcare settings can help identify any gaps in practice and ensure
adherence to guidelines. This process enables the identification of areas for improvement.