Jacqui Hunter died during childbirth after being given a high dose of Misoprostol; the Nursing and Midwifery Council says there is no current case to answer despite acknowledging serious practice concerns.
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The Nursing and Midwifery Council found a realistic possibility the alleged facts about the medication error could be proved but decided there is no realistic possibility the midwife’s fitness to practise is currently impaired.
The husband, Lori-Mark Quate, has sought a review of the NMC decisions and says the process has been protracted and lacks accountability.
# What happened
Her husband, Lori-Mark Quate, learned later that Misoprostol had been administered and subsequently referred the case to the Nursing and Midwifery Council (NMC) in June 2021.
# Regulator findings and response
Despite that, the NMC decided there is "no realistic possibility" that the midwife's fitness to practise would be found currently impaired. The examiners treated the incident as isolated and noted it occurred more than six years earlier. They said they had no information suggesting other concerns about the midwife's practice.
Quate alleged failed to properly assess Ms Hunter or escalate care after reported reduced fetal movements.
# Family reaction and accountability concerns
Mr Quate described the process as "protracted" and "materially flawed." He said the lack of formal accountability felt like a ''special kind of cruelty'' and that he wanted "some genuine recognition that what was done was wrong. Real accountability."
He criticised the regulatory system for allowing those responsible to "move on" without consequences and said that if a drug error occurs the person administering it should not be in a position to decide whether the patient is left unaware of what happened.
# Clinical context noted by reviews
An NHS Tayside review panel, noted in related reporting, observed that while amniotic fluid embolism can occur in any labour, higher doses of Misoprostol increase risk in rare cases. An expert who gave evidence to a fatal accident inquiry said it was possible, but not probable, that the death could have been prevented had the correct dose been given.
# What the NMC flagged and what it did next
The NMC acknowledged that, if proven, the midwife's conduct could have exposed patients to a significant and unwarranted risk of harm. The examiners warned that if such conduct is not addressed it could put future patients at risk. Nonetheless, they declined to refer the case to a fitness to practise hearing on the basis that the necessary threshold for current impairment was not met.
Mr Quate has asked the NMC to review both decisions, continuing his pursuit of accountability. The case sits within wider reporting on maternity services across Scotland that includes rising complaints and concerns about staffing and safety.
# Practical takeaways
NHS Tayside says its systems and processes have been ‘strengthened’ where required
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Commissioner says ‘sustained’ rise in complaints must be dealt with ‘systemically’
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