Red flags in clinical practice: expert insight on maternity care and red flags

The fourth article in our "Red Flags in Clinical Practice" series focuses on maternity care.

By Rachel Makore, Associate Clinical Negligence Solicitor

In my work as a clinical negligence solicitor, I regularly act for clients where a serious condition was not identified at the earliest opportunity.

A common feature in many of these cases is not a lack of clinical knowledge, but a failure to recognise, properly weigh, or act on key features in a patient’s presentation.

This forms part of our “Red flags in clinical practice” series, where frontline clinicians share insights into recognising time-critical conditions and understanding how delays in diagnosis can occur.

By exploring these issues from a clinical perspective, alongside the medico-legal context in which they often arise, the aim is to provide a clearer understanding of how delays in diagnosis occur and the very real consequences they can have for patients.

In this fourth article, you can read the previous articles here, Claire Darling, Registered Midwife & Expert Witness, highlights two maternity red flags, why they happen and how they can be avoided.

Introduction

I am a senior NHS midwifery leader with extensive experience in high-risk antenatal and intrapartum care, maternity governance, patient safety, regulatory review and medico-legal expert witness work.

Alongside operational leadership, I undertake independent expert reviews of midwifery care. This experience has shown that poor maternal or neonatal outcomes are rarely attributable to a single source. More commonly, concerns develop over time but are not recognised as a changing pattern. Warning signs may be present, yet risk is not reassessed or escalation is delayed.

Operational pressure and high levels of clinical activity may explain how a situation developed, but they do not remove the duty to provide safe assessment, monitoring and escalation.

Two maternity red flags are particularly important from both a clinical and medico-legal perspective: delay following initial maternity triage, and failure to reassess risk and identify maternal or fetal deterioration.

Red flag 1: Delay in triage while awaiting senior review

After 16 weeks’ gestation, women are commonly advised to contact maternity triage if they have concerns about their own wellbeing or that of their baby. Presentations may include reduced fetal movements, vaginal bleeding, abdominal pain, suspected labour or symptoms of hypertension.

As these presentations vary in urgency, maternity services require a structured triage system. Initial assessment should identify women who require immediate intervention, urgent clinical review or who can safely wait.

However, timely initial triage does not remove the risk of subsequent delay. A woman may be assessed promptly by a midwife but then wait for continuing care, senior obstetric review, transfer to the labour ward, or access to another clinical area. During busy periods, medical staff may be managing competing emergencies and an apparently stable woman may wait while the underlying condition progresses.

The red flag is not simply the length of the wait. It is delay without a documented level of urgency, an agreed timeframe for review, repeat assessment, named clinical ownership or further escalation when the expected response does not occur.

In pressured services, delay can become normalised. Once a woman has been categorised as lower risk, midwives may continue to view her through that initial assessment, even when circumstances change.

From a medico-legal perspective, the central question is whether a competent midwife would have obtained senior review, investigation, transfer or intervention sooner. Where earlier review would probably have led to earlier treatment or birth, the delay may have contributed to avoidable harm.

Red flag 2: Failure to reassess risk and identify deterioration

The second red flag is failure to recognise that the woman or baby is deteriorating while awaiting care or during an ongoing assessment.

Deterioration may be indicated by changes in the fetal heart rate or maternal observations, increasing abdominal pain, vaginal bleeding, repeated attendance or telephone contact, or the woman repeatedly expressing that something is wrong.

Warning signs may be recognised individually but not brought together into a coherent clinical picture. Observations may not be repeated, the significance of a changing CTG may not be appreciated, or the woman’s concerns may not be given sufficient weight.

Escalation may also be ineffective. A clinician may be informed but fail to attend. Repeated escalation can create a false impression that action has been taken when no senior obstetrician has reviewed the woman and no definitive plan has been made.

Loss of one-to-one care may increase this risk. When midwives are caring for several women, or the coordinator carries a clinical caseload, situational awareness and oversight are reduced. A changing fetal heart pattern or deteriorating maternal condition may not be fully appreciated until an emergency develops.

Clinical and medico-legal considerations

Risk assessment must be dynamic. A triage category, or an initially reassuring assessment is valid only at the time it is made and must be reviewed when symptoms, observations, fetal monitoring or the woman’s concerns change.

Escalation should be proportionate to the risk and continue until an appropriately senior obstetrician has reviewed the woman and a clear plan has been implemented. Recording that escalation occurred is insufficient. The clinical record should demonstrate the concern, when it was recognised, who was informed, the urgency communicated, the response received, any repeat escalation and the resulting plan.

Medico-legal cases often focus on whether deterioration was foreseeable and whether there was a reasonable opportunity to intervene. Where abnormal fetal monitoring, deteriorating maternal observations or repeated maternal concerns were present but senior review, transfer, theatre access or birth was delayed, the standard of care may fall below that expected of any reasonably competent midwife.

A busy ward is relevant context, but it is not a defence to failing to recognise and escalate a deteriorating or time-critical patient.

Case example

A woman at 40 weeks’ gestation contacts maternity triage reporting reduced fetal movements and is advised to attend. She receives an initial assessment, and continuous fetal heart monitoring is commenced.

The CTG is initially reassuring but subsequently deteriorates. The midwife contacts the obstetric trainee, but review is delayed because of competing emergencies. The woman’s risk is not formally reassessed, no clear timeframe for review is agreed and she is not transferred to the labour ward for one-to-one care and obstetric assessment.

Although concerns have been communicated, no individual takes clear ownership. By the time an emergency response is activated, opportunities for earlier review, transfer and intervention have been missed.

If I could change one thing…

Maternity services already have processes for prioritisation, reassessment, clinical ownership and escalation. The key improvement is to ensure these remain effective during busy periods, competing emergencies or staffing pressure.

Women awaiting senior review, investigation, transfer or treatment should continue to have their urgency reviewed and their condition reassessed at appropriate intervals. Where review is delayed or the clinical picture changes, escalation should be repeated and documented.

Effective escalation routes should be available when obstetric colleagues or senior midwives cannot attend. Changes in symptoms, maternal observations, fetal monitoring and concerns expressed by the woman must remain central to ongoing risk assessment and decision-making.

Contact Dean Wilson LLP

If you or a loved one has concerns about maternity care, our clinical negligence team would be happy to offer initial guidance. Please contact us for a free and confidential discussion on 01273 249200 or visit our Medical Negligence page for further information.