Expert Witness Journal Issue 65 February 2026 - Flipbook - Page 38
mother was admitted to hospital by ambulance at
0010 on 1 September 2011 and the Claimant was
born by caesarean section at 1019 on 2 September
2011. Apgar scores were 5 @ 1 minute; 7 @ 5 minutes
and 6 @ 10 minutes. The arterial cord pH was 7.01
and the venous cord pH 7.08. Before admission
to hospital the Claimant’s mother had had a
spontaneous rupture of membranes and described
some heavy blood loss when phoning the midwifery
unit. On admission minimal blood loss was noted on
the Claimant’s mother’s pads.
on to a registrar after admission, I consider that a
reasonable body of midwives would have acted as
midwife Coliandris did, so she was not in breach. I
should make clear that in my judgment, Ms Brydon’s
opinion at least represents that of a small but
reasonable body of the profession and more probably
represents the standard of care of the majority in
2011, because it was more logical and better matched
the advice in Myles Midwives 15th ed (2009) at pages
336-337. Having carried out every proper assessment
and examination, having noted that all the signs
came back normal for both M and C, in the context
of mere BSL on the maternal pad and taking into
account the great di昀케culty for mothers accurately to
assess the amount of blood loss in a toilet after SROM,
furthermore taking into account the paramedics’ note
of what M told them (some bright red watery blood),
referral to a registrar at 00.50 am was not mandated
and might, quite rightly, have led to a raised obstetric
registrar’s eyebrows.”
The issues in the case related to the standard of
midwifery care after admission to hospital and
the level of obstetric intervention on the following
morning. The main issue was to determine when
the insult causing brain damage had occurred as
unusually the Claimant’s condition at birth was not
easily reconcilable with a severe insult just before
delivery.
The Judge found there was no breach of duty in
the care by the midwives in not asking for obstetric
assessment after the mother’s admission to hospital.
He stated:
“
And
“
I was greatly assisted by both midwifery experts who
were of high professionalism and focus. Their opinions
were also logical, from their points of view. However,
Ms McConville mistakenly wrote that there was
continuing fresh bloodstained liquor on admission.
I 昀椀nd that there was no “fresh” BSL, only BSL. In
her report, she considered that the maternal report
of heavy bleeding at home was enough to mandate
medical referral despite: (1) what M had said to the
paramedics (”some bright red watery blood”); and
(2) all the examinations and assessments of M and
C being reassuringly normal; and (3) the di昀케culty for
any mother in estimating blood volume in liquor in
a toilet after SROM. I consider that Ms McConville
stretched the meaning of the extracts from the text
books which she relied upon a little further than they
actually went. Not one of the texts stated that medical
referral was mandated where SROM and BSL have
arisen, against a background in which all of the
examinations, signs and the CTG are normal, just
because a mother had reported a heavy bleed at home.
Ms Brydon advised that the reason for doing all the
examinations and assessments was to determine
whether M or C was at risk of having su昀昀ered an
APH at home and the results did not support APH.
Instead, the results supported SROM (which was
con昀椀rmed on speculum examination) and BSL,
which was common with SROM.”
The Judge criticised both expert obstetricians for
commenting on the standard of midwifery care.
“
“
Overall, once Ms McConville had shifted her opinion
in cross examination, I consider that the di昀昀erence
in opinions between the experts represented a
reasonable range of opinions for midwives in practice
in 2011. Thus, where Ms Brydon advises that midwife
Coliandris was not negligent for failing to refer M
EXPERT WITNESS JOURNAL
Mr Mason went outside his 昀椀eld of expertise when
advising the Court that midwife Coliandris breached
her duty of care because she should have referred M to
obstetricians and should have identi昀椀ed the source of
the bleeding, soon after admission. That was for the
midwifery experts. In any event, Mr Mason altered
his opinion on referral to an obstetrician from a
blanket mandation, due to M’s self-report over the
telephone, to a requirement only if there was evidence
of signi昀椀cant blood loss as opposed to SROM with
BSL. Professor Thornton made a serious error in his
report and in the joint report when he overlooked the
fresh blood seen by the midwife at 08.35 am and the
report by M of fresh blood in the toilet in the same
note. He also strayed outside his 昀椀eld to comment on
midwifery practice. In relation to the allegations of
breach relating to midwifery practice, I prefer to rely
on the midwifery evidence and I have done so above.”
The Judge found there was however a breach of duty
by the obstetrician at 0848. The Judge was critical of
the Defendant’s obstetric expert and his analysis of
this and stated:
And
“
As for the actions of the morning midwives, midwife
Rogers was involved in the call for obstetric review
via her coordinator, Ms Hall, very soon after 08.35
am and that is what the midwifery experts both agree
she should have done, so I consider that she was not
in breach of her duty of care.”
36
Both experts criticised Mr Siddig’s diagnosis made at
08.48 am, of a local source for the bleeding. The most
unimpressive part of Professor Thornton’s joint report
was his advice on the events at 08.48 am. Despite
Mr Mason pointing out to him that there had been
“fresh bleeding” he ignored that and wrote: “ There
was no indication to undertake a caesarean at 08.48
FEBRUARY 2026
