Reasons for the substantive hearing of the Conduct and Competence

Committee panel
held at
Four Pillars Spires, Abingdon Road, Oxford
On
10-13 November 2008

Name: Sarah Ruth Samuel Montagu

PIN: 88I1382E
Part (s) of register: Registered Nurse- Adult
Registered Midwife

Facts proved: 1(i); 2(i), 2(iii), 2(v), 2(vii); 4; 6

Facts not proved: 1(ii), 1(v), 1(vi), 1(vii), 1(viii), 1(ix); 2(ii), 2(viii), (2(ix), 3; 5; 7; 8
Fitness to practise: Impaired
Sanction: Conditions of Practice Order for 12 months
Interim Order (if Interim Conditions of Practice Order for 18 months
applicable):

Charges read as follows:

That you, during the period from May to November 2005, whilst employed as an
Independent Midwife, under the Supervision of West Midlands NHS Local
Supervising Authority:

1. failed to act in the best interests of your clients, Mr and Mrs A, more
particularly, you:

i.) Failed to sufficiently impress on your clients, the increased risks and/or
difficulties entailed managing a twin home water birth for a woman with a
history of two caesarean sections, Consultant Unit Care and Delivery and
Obstetric Cholestasis (“OC”).

ii.) Failed to diagnose twins despite early indications.

iii.) Failed to adequately monitor the condition of Obstetric Cholestasis (“OC”)

via communications with the hospital.

iv.) Attempted to induce labour on three separate occasions without adhering

to NICE Guidelines or best practice.

v.) Failed to have a third midwife present for the second stage of labour.

vi.) Failed to recommend early action and/or inform your client during labour
of your concerns.

vii.) Failed to follow best practice and/or your own guidelines fro monitoring
the twin fetal heart beats in labour.

viii.) Failed to listen to your client and/or follow her Birth Plan.

ix.) Failed to inform the hospital and/or ambulance staff that it was a red alert
transfer.
2. failed to maintain accurate and consistent antenatal and assessment records,
more particularly, you:

i) Failed to record why blood tests were not carried out at booking.

ii) Failed to record a risk assessment in relation to Mrs A.

iii) Failed to record details of discussions with the Head of Midwifery and
Consultant Obstetrician.

iv) Failed to record why Mrs A went for a blood test at 34 weeks.

v) Failed to record the method of fetal monitoring.

vi) Failed to update the maternity notes between 5.45 am and 8.00 am
during labour.

vii) Failed to record the client’s temperature and/or the descent of the
presenting part and/or the strength of contractions on the Partogram.

viii) Failed to record expressions of concern when fetal tachycardia

identified.

ix) Failed to record the emergency situation on transfer and/or the

transfer to hospital.

It is alleged, that whilst working as an independent midwife on 25 April 2006, you

showed disregard for the safety of your client, B, and her unborn child, C, more
particularly you:

3. failed to make alternative arrangements regarding your meeting in London when

your client called at approximately 11.41am to inform you her cervix was for-
shortening;

4. failed to prioritise your client by taking steps to return to Oxford when she called a
second time at 12.39pm to update you with her symptoms;

5. attempted to assess your client’s progress over the telephone;

6. failed to advise your client to go to hospital for an assessment in your absence;

7. failed to carry out a suitable and/or sufficient risk assessment as to the likelihood
of your client labouring early;

8. failed to take immediate steps to get to your client when she told you at
approximately 3.45pm she was experiencing regular contractions lasting 50
seconds every 8 minutes;

9. failed to provide a true and accurate account of the circumstances leading up to

the birth of C and/or thereby attempting to mislead the subsequent investigations
into this incident;
and in view of the above your fitness to practice is impaired, by reason of
misconduct.

Reason for the finding of facts

I shall read out first the Panel’s reasons for our findings in relation to the charges we
have found proved.

1(i) We are satisfied by reference to Rule 6 of the Midwives Rules & Standards
produced by the NMC, (a document not formally put before us during the hearing but
of which we have taken professional notice ourselves), that Ms Montagu was under a
duty to discuss fully with her clients, Mr and Mrs A, the risks involved in the kind of
birth proposed by Mrs A.

We accept that Ms Montagu had several, often long, conversations and discussions
with Mrs A, both by telephone and in person, both before the diagnosis of twins and
after, and both before the meeting with Mr Cohn, Consultant Obstetrician, on 24
October (2005) and following it, during the course of which she will have discussed,
as she put it in her notes, “the pros and cons” of Mrs A’s chosen course of action.

However, we are firmly of the view that Mrs A represented such a high risk case that
Ms Montagu was under an even higher duty than normal to highlight in clear and
focused detail the particular risks inherent in her case. The factors that in our view
placed Mrs A in this high category of risk are as follows: she had had two previous
caesarian sections; she had had no previous vaginal birth; she had a history of
augmented labour; twins were diagnosed in the latter stages of pregnancy; she had
been diagnosed with obstetric cholestasis; she lived in a relatively isolated rural
location and had expressed a strong desire to commence labour at home.

We have neither seen nor heard any evidence to satisfy us that she spelt out with
sufficient emphasis the increased risks which would arise as a consequence of the
circumstances that presented themselves, for example following the diagnosis of
twins. And following the meeting with Mr Cohn, at which he had set out the issues in
robust and comprehensive terms, we would have expected Ms Montagu herself to
have rehearsed the exceptional risks that were now apparent in this case. We find as
a fact that she should have done so.

We make these findings notwithstanding the fact, which we fully acknowledge, that
Mrs A herself was well-informed, articulate and possessed of strong and decisive
views of her own. We note in passing that in Mrs A’s birth plans there is no sign of
any amendment to take account of the increased risks or difficulties in managing the
birth following the diagnosis of twins.

We are therefore drawn to the conclusion, and are satisfied to the requisite standard,
that Ms Montagu failed in this regard to act in the best interests of her clients as
alleged.

Moving on to the facts in charge 2, we should make it clear that while there was
some discussion between the Legal Assessor and the NMC’s Case Presenter
regarding the wording of the stem of the charge, we note that no point was taken on
behalf of the Registrant either at the beginning of the case or during the course of Ms
Hewson’s half time submissions. In the circumstances we have adopted effectively a
purposive construction of the charge as drafted, without imposing the strictest
definitions of “accurate and consistent”.
2(i) We find as a fact, and it was not seriously challenged, that Ms Montagu did
not record that Mrs A had declined blood tests. In turn we are satisfied that the
records were inaccurate in the sense that they did not provide a complete account.

2(iii) We are satisfied, pursuant to the NMC’s Guidelines for records and record
keeping, that there is a fundamental duty on nurses and midwives to record details of
discussions with senior healthcare professionals regarding the care of a particular
patient or client.

As regards Ms Montagu’s discussions with Ms Gauler, acting Head of Midwifery and

Supervisor of Midwives, we are not satisfied that their meeting was exclusively of a
supervisory nature. The fact that Ms Montagu reported back to Mrs A following the
meeting leads us to find that she should have provided more detail in the notes than
the mere statement that it had been a useful meeting.

As regards the meeting with Mr Cohn, we note that he (unusually, as we accept)

made his own brief entry in Ms Montagu’s records. However, we would have
expected her to supplement his entry with her own more detailed one, particularly
since there had been a discussion regarding her management of the birth in the
context of the risks which Mr Cohn had expressly identified. We regard her failure to
do so as a material breach of her duty in relation to record keeping as charged.

2(v) We note that Ms Montagu had completed this entry on assessment and on
each of her antenatal visits. Furthermore we accept that she was meticulous in
undertaking fetal monitoring every 15 minutes. However, on a strict reading of the
charge relating to the method of monitoring, we have to accept that from midnight
she failed to record this particular detail.

2(vii) On the basis of our perusal of the records we are satisfied that Ms Montagu
did record the strength of contractions on the Partogram. However we are also
satisfied that she did not record Mrs A’s temperature or the descent of the presenting
part.

4. We are satisfied that as a breech birth this was always going to be a high risk
birth with increased potential for complications. We further accept that there were
relatively few midwives with the relevant experience, which Ms Montagu undoubtedly
did possess, to manage a breech birth at home. The evidence is clear and we are
wholly satisfied that Mrs B had placed considerable reliance on Ms Montagu
personally. In the circumstances it was crucial for Ms Montagu to be present at both
labour and birth.

By the time of this call, 12.39pm, there had been some changes in Mrs B’s condition
and it would appear that she was now progressing towards labour. Although she was
not experiencing regular contractions, we accept Mrs B’s graphic evidence that
having had a surging kind of contraction in Tesco, she experienced further “surges”
on her return home and had another one, albeit not very strong, while on the
telephone to Ms Montagu.

Professor Page postulated that this might have been a latent stage of labour, in
which case we are satisfied it was unlikely to be a protracted process as this was not
a first birth.
Against this background, we are satisfied that it was manifestly unwise for Ms
Montagu, who was already many hours away from Mrs B, to proceed even further
away from her client to her meeting in Wimbledon.

In light of the sheer logistical uncertainties involved in getting from Wimbledon to

Solihull via Southfields, Paddington and Oxford, using every form of transport from
rush hour tube train to bicycle, we feel bound to find that Ms Montagu displayed a
degree of brinkmanship at this stage which does in our view represent a failure on
her part to prioritise the interests of her client, given that the pregnancy was at term.

We are therefore satisfied that in failing to consider the contingencies of a worst case
scenario she did show disregard for the safety of her client. Simply asking Mrs B if
she wanted her to return then, as Mrs Montagu claimed she had, was not in our view
sufficient.

6. We are satisfied that a time would have come at some stage during the day when
Ms Montagu, having received an unprecedented number of telephone calls from Mrs
B, should have advised her to go to hospital for an assessment. In particular, we
heard unequivocal evidence from Mrs B that in anticipation of her telephone call at
3.45pm she was concerned that “things were getting stronger” and that “it was going
to be too fast” for Ms Montagu to get to her in time. Mindful of Professor Page’s
opinion at page 19 of her report that “if Mrs B had doubts about where and how to
deliver ... she should have been advised at this stage to go to the hospital”, we are
satisfied that in failing to provide that advice Ms Montagu did show disregard for the
safety of Mrs B and her unborn child.

Turning to the charges which we have found not proved, our reasons are as follows:

1(ii) It is not in dispute that Ms Montagu did not diagnose twins. However, we are
not satisfied that the early indications, which were subjectively identified by Mrs A,
were sufficiently apparent as clinical indications to put Ms Montagu on further inquiry.
We feel it is appropriate to observe that Ms Montagu measured the fundal height
regularly - indeed more regularly than usual practice requires.

1(v) We accept the evidence of Ms Montagu that if Mrs A’s labour had developed
to a point where the presence of the third midwife would have been necessary she
would have contacted her; and if she had said that she could not come due to
continuing bad weather conditions, she, Ms Montagu, would have made alternative
arrangements. However that stage had not been reached. Ms Montagu’s evidence
was effectively corroborated by that of Susan Blackburn, the second midwife, whom
we regarded as a genuinely independent and truthful witness.

For the avoidance of doubt, we are satisfied that not only had Mrs A not reached the
second stage of labour, but she had not reached the stage where it would have been
necessary to summon the third midwife. Furthermore, we are satisfied that even if the
third midwife had not been able to get there, there was still sufficient time for Ms
Montagu to obtain the services of a paramedic, community midwife or other
healthcare professional.

1(vi) The contemporaneous notes kept by Ms Montagu provide a clear chronology

of the development of the tachycardia. We see no reason not to accept these notes
as an accurate record of events and we are satisfied that Ms Montagu acted in a
proper manner as regards keeping her clients informed of her developing concerns.
1(vii) In order to establish whether Ms Montagu had failed to follow best practice for
monitoring twin fetal heart beats in a home birth setting, we would have had to be
clear ourselves what that best practice is or was. However Mr Millard on behalf of the
Council failed to assist us in this regard and so we cannot find this limb of the charge
proved.

As regards Ms Montagu’s own guidelines, we note that she favoured the approach of
Ms Mary Cronk but did not follow her guidelines on this occasion. However we
accept that the Cronk guidelines were not official, clinical based guidelines, but rather
were personal to her and certainly not binding. In the event, we are satisfied that Ms
Montagu did her best in difficult circumstances and managed to record regularly the
fetal heart rates of both twins.

1(viii) We are satisfied, taking the evidence in the round and with particular
reference to the notes, that Ms Montagu was indeed listening to Mrs A and formed
the professional judgement that she was not serious about wanting to go to hospital.
We accept that Ms Montagu sought express confirmation from her and that Mrs A did
not reply. In this respect the oral and written evidence of Ms Montagu is corroborated
by that of Ms Blackburn, and even at one point by that of Mr A.

With regard to Mrs A’s Birth Plan, we note that there was nothing set out explicitly in
that document about transferring to hospital because of pain of labour. Indeed it was
always understood that a transfer would be for the purposes of caesarean section.
Moreover it was clear from the birth plan that the final decision lay with Mrs A; in the
event, when offered the option to transfer, she gave no indication of wishing to move.

1(ix) We are satisfied that when the decision was taken to transfer to hospital it
was because of non-reassuring fetal heart rates rather than clinical signs of fetal
distress or maternal abnormality. In the circumstances, at the time Ms Montagu
communicated with the hospital and the ambulance team it was reasonable for her to
proceed on the basis that this was an urgent transfer, not an emergency one, such
as might warrant the description of “red alert”. We note incidentally that the hospital
records corroborate in all material respects Ms Montagu’s own record of her call.

2(ii) We accept that as a matter of midwifery practice the maternity records taken
as a whole represent a form of risk assessment. In turn we are satisfied that there is
no duty on a midwife to complete a stand alone risk assessment document.

While the lay members of the Panel took the view that there could well be merit in
such a document on occasions, we recognise that it is not for us to impose a higher
duty simply because of the exceptional circumstances of this case.

2(viii) As Ms Hewson observed in her closing submissions it is not clear whose

expressions of concern are being referred to in this charge. Mr Millard on behalf of
the Council appears to have proceeded on the basis that it related to the Registrant,
a view that was shared by the Legal Assessor. Our own view at the half time stage
was that it was likely to have referred to Mr A.

On a further perusal of the transcripts we are still not satisfied that this ambiguity has
been satisfactorily resolved.

What we are sure about is that a Registrant is entitled to be clear as to the nature of
the charge she is facing. The fact is that the Council has not clarified the position
during the course of the hearing, and so we cannot find this charge proved.
2(ix) Since, as we have already determined, we are satisfied that this appeared to
be an urgent rather than an emergency situation, we must necessarily find this
charge not proved.

3 We are satisfied, on the basis of the telephone records and the oral evidence
of Mrs B which we have no reason to disbelieve, that a telephone conversation took
place with Ms Montagu at approximately 11.41am effectively in the terms as alleged.

The weight of evidence would suggest, and we so find, that Mrs B had reached the
stage where she might be showing early signs of labour, but that labour was not
necessarily imminent.

We do take particular account of the following factors, which we have alluded to

already: this was likely to be a birth where complications might arise; there were
relatively few midwives with the relevant experience to manage a breech birth at
home; Mrs B had placed considerable reliance on Ms Montagu personally. In the
circumstances it was going to be particularly important for Ms Montagu to be present
at labour and birth.

Notwithstanding these factors, we cannot find that Ms Montagu, in deciding at this

stage not to change her plans but to agree with Mrs B that they should continue to
monitor the situation, showed disregard for the safety of her client.

5 We accept the expert evidence of Professor Page that not only is it

acceptable for a midwife to assess her client’s progress over the telephone, it is
sometimes necessary. Indeed we are satisfied that it is an important tool of triage.

7 We are satisfied that there is no suitable or sufficient predictive test or means

of assessment for determining the likelihood of labouring earlier than the due date,
and in this regard we accept the evidence of Professor Page.

8 We frankly regard this charge as unrealistic. We accept that Ms Montagu left

her meeting five minutes after receiving Mrs B’s telephone call. Short of flying by
helicopter, as lightly suggested at one point by Mrs B, we are satisfied that there
were no immediate steps that Ms Montagu could practicably have taken to get to Mrs
B earlier than she did.

Reason for the finding of impairment

In considering the question of impairment we have reminded ourselves that it is

essentially a two stage test and that we must first make a finding as to whether any
of the facts we have found proved amount to misconduct. As the legal assessor
noted, we can not find impairment without a finding of misconduct; but it is
conceivable that we might find misconduct established but not be satisfied that such
misconduct amounts to impairment.

We should further observe by way of preamble that even in cases where a Registrant
admits misconduct and/or impairment it is still necessary for us as a panel to make
our own determination. In this case Ms Hewson on behalf of Ms Montagu has
conceded that with the benefit of hindsight her client made some errors of judgement.
However, she has not admitted misconduct in relation to any of the charges which we
have found proved, and - as is Ms Montagu’s right - has effectively left it to us to
make the substantive determination.
Ms Hewson in her written and oral submissions has quite fairly suggested that some
of the charges which we have found proved are less serious than others. Certainly in
relation to Mrs A’s case, the charges relating to record keeping and the completion of
the partogram would in normal circumstances, and separately, be categorized as
relatively minor failings on the part of Ms Montagu. Indeed in relation to her failure to
record the particular method of fetal monitoring she used we make no criticism at all
of Ms Montagu. However, when seen cumulatively and in the particular
circumstances of this case, we are satisfied that her other failings regarding record
keeping do amount to misconduct.

It cannot be repeated too often that proper record keeping is a fundamental tool of
communication within the multi-disciplinary health care team. That principle must
apply to independent midwives just as much as it does to any other nurse or midwife.
We do not doubt that Ms Montagu would agree. However we have been concerned
that while the standard of her record keeping is generally high and is likely to have
been sufficient for the purposes of her normal practice, there is a certain lack of
transparency in her recording both of clinical findings and what she has explained to
her client that can take on an added importance when other care professionals
necessarily become involved.

Thus in a high risk case such as that of Mrs A, where there was a significant
likelihood that Mrs A might have to be transferred urgently to hospital, we are
satisfied that there was a particular duty on Ms Montagu to ensure that her records
were clear and obvious to hospital staff if and when care duly was transferred. In turn
we are satisfied that she failed in this regard, and that that failure amounts to
misconduct.

So, for example, while Ms Montagu was all too familiar with the reasons why Mrs A’s
blood tests had not been done, the receiving staff, who would inevitably look for
these records as a matter of priority, would require explanation or clarification as to
their absence. This could result in unfortunate delay. Ms Montagu was herself
present at this particular handover, but that could not be guaranteed in every case.

Similarly, with regard to the partogram, in an urgent transfer in labour, this tool of
communication takes on a particular importance since it is likely to be the first
document that the receiving staff will look at. Again, any material failures in its
completion, as in this case regarding the history of the mother’s temperature or a
record of the descent of the presenting part, could result in a delay in making a
proper assessment. In a case of transfer because of fetal tachycardia, as here, the
hospital staff will want to be satisfied that a rise in the maternal temperature is not the
root cause. It is frankly impractical to expect them to sift through Ms Montagu’s more
detailed notes in such circumstances.

We turn now to the Registrant’s failure to record details of her discussions with Ms
Gawler and Mr Cohn. At the risk of repeating what we said in our reasons at the fact
finding stage, we are satisfied that any concerns that Ms Montagu discussed with Ms
Gawler, for example regarding the dating scan being declined and her difficulty with
palpation, should have been recorded in the notes, with all due sensitivity, of course.

Equally, having previously identified a baseline of Mrs A’s risks, Ms Montagu should
have reiterated the risks that were highlighted by the consultant, Mr Cohn, and any
other material issues discussed with him regarding Ms Montagu’s own management
plans and capabilities.
As we have previously found, we regard these failures as amounting to a material
breach of Ms Montagu’s duty in relation to record keeping. We now go further and
say that it does in our judgement amount to professional misconduct on her part.

We make the same finding in relation to Ms Montagu’s failure to impress on Mr and

Mrs A the increased risks of Mrs A’s chosen course of action. We remind ourselves
that we found as a fact, for reasons which we set out in some detail under charge
1(i), that Ms Montagu had failed in this regard to act in the best interests of her
clients. We would find it difficult to conclude that this did not amount to misconduct.

We wish to stress, in light of a specific submission by Ms Hewson, that we are not for
a moment suggesting that Ms Montagu should have tried expressly to persuade Mrs
A to change her mind. Our finding that she should have highlighted in clear and
focused detail the particular risks inherent in Mrs A’s case does not amount to a
retrospective direction that she should somehow have applied moral pressure on Mrs
A or otherwise sought to ensure that she opted for a particular course. Having said
that, we do remain of the view that Mrs A’s case was towards the highest end of the
scale of risk. And while the risks were robustly and, we might add, sensitively
identified by Mr Cohn, Ms Montagu’s own observations appear to have been limited
to providing reassurance that the case was within her comfort zone, or words to that
effect.

It may well be, as Ms Hewson submits, that Ms Montagu was seeking to respect her
client’s sensitivity and did not want to alienate her. However, in our view that merely
highlights a tendency on Ms Montagu’s part to have concentrated disproportionately
on maintaining a good relationship between herself and Mrs A.

In her desire to avoid any possibility of upsetting or offending Mrs A, Ms Montagu ran
the risk in our view of failing to prioritise properly her safety and well-being. We
recognise that it can be difficult to deal with a challenging client such as Mrs A,
possessed as she was of strong and decisive views and a hostility, quite possibly
with good reasons of her own, towards NHS health care professionals. However, we
are sure that it is possible for an independent midwife like Ms Montagu to give a clear
and straight account of the risks and implications of even a demanding client’s
chosen course, without necessarily causing offence or losing her trust and
confidence. Indeed, we are satisfied that there is a duty to do so, pursuant to the
guidance in Rule 6 of the NMC’s Midwives Rules and Standards, and we quote:

“If you judge that the type of care a woman is requesting could cause
significant risk to her or her baby, then you should discuss the woman’s
wishes with her; providing detailed information relating to her requests,
options for care, and outlining any potential risks, so that the woman may
make a fully informed decision about her care.”

We note that following our findings of fact Ms Montagu now acknowledges with the
benefit of hindsight that she got the balance wrong. We are satisfied that in this
regard she fell below the standards reasonably expected of a registered midwife and
that her failure amounted to misconduct.

In turn we are satisfied that Ms Montagu tended to lose some of her objectivity when
dealing with Mrs A. Apart from the acknowledgement we have just referred to, which
was contained in Ms Hewson’s submissions, we have heard no evidence to lead us
to find that there has been any material change in Ms Montagu’s practice.
Ms Hewson has made a similar concession in relation to the case of Mrs B, to the
effect that Ms Montagu accepts she made an error of judgement in not returning
more promptly from London to Oxford. Again we are bound to observe that we have
heard no direct evidence from Ms Montagu in this regard.

We do not feel it is necessary to rehearse here the history of Mrs B’s case or our
detailed findings of fact in relation to it. Suffice it to say that having found as we did
that Ms Montagu failed to consider the contingencies of a worst case scenario and
thereby showed disregard for the safety of her client, we are inevitably led to
conclude that her conduct amounted to misconduct. Our assessment in this regard is
further strengthened by the fact that Ms Montagu had failed to put any proper
contingency plans in place in a case involving a high risk pregnancy at term, where
the client clearly relied so strongly upon her and Ms Montagu already lived so far
away from her client.

These could have included the option of a hospital assessment. As we further found,
in failing to heed the apparent concerns of Mrs B and advise her to go to hospital for
an assessment, Ms Montagu showed disregard for the safety of Mrs B and her
unborn child. For the avoidance of doubt we are satisfied that this failure too amounts
to misconduct on her part.

We note that Ms Hewson in her submissions states that the Registrant has learnt a
key lesson from this unfortunate incident. But again, we must stress that this is a
submission rather than evidence. We repeat that we have heard no evidence, either
from Ms Montagu herself or from any other health care professional, to the effect that
her practice is now materially different.

In all the circumstances we are satisfied that Ms Montagu’s fitness to practise was,
and remains, impaired by reason of the misconduct we have found established.

Reason for the sanctions

In considering the question of sanction we took full account of the Indicative

Sanctions guidelines provided by the NMC.

We began by considering whether to impose no sanction. However we were satisfied

that the charges which we have found proved and which we have determined
amount to misconduct were so serious that it would not be in the public interest to
take no further action.

We next considered a caution order, and paid particular regard to the factors set out
in the NMC’s indicative sanctions guidance document.

We accept that Ms Montagu had a previous good history of knowledgable and

supportive midwifery practice, and we have read carefully the bundle of very positive
references from former clients, amongst whom were a number of health care
professionals. We should, however, observe that the vast majority of these
references predate these NMC proceedings and we surmise that the referees were
not aware of the specific charges that Ms Montagu was facing, particularly those
relating to Mrs B.

We were concerned that, apart from the mitigation evidence of Ms Montagu herself
and Ms Hewson’s submissions, we certainly heard no testimonials that related
directly to the issues which led to our finding of impairment. We were surprised and
disappointed, for example, that we did not hear from a supervisor of midwives,
another independent midwife or any other health care professional.

We accept that Ms Montagu has not been involved in any further incidents of the kind
which brought her before the NMC, and we note that she has taken steps to reduce
the number of high risk clients she has taken on, at least during the course of these
proceedings.

However we remain concerned by what we see as a continued lack of insight on her

part, notwithstanding the assurances we received from Ms Hewson and the
concession made by Mr Millard on behalf of the Council.

We were not convinced that Ms Montagu had thought through the implications of our
findings on the future management of her practice. While making allowances, of
course, for the stress she has been under, we were dismayed that she was unable to
articulate clearly how she might change her practice in the future, for example in
terms of the weight of her caseload or its geographical spread. We regret to say that
we were not encouraged by her answers that she had developed sufficient insight in
relation to risk planning and record keeping when dealing with high risk or especially
demanding clients. Nor did she convince us that she had developed the necessary
insight to be able to balance and prioritise the various needs - physical, emotional,
logistical - of her often challenging clientele.

Finally we reminded ourselves of our duty to have regard to the public interest, in
particular the importance of upholding proper standards of conduct and performance
and maintaining public confidence in the midwifery profession and the NMC. While
we are satisfied that Ms Montagu is indeed a highly experienced and professional
midwife, we felt bound to conclude that a caution order would not address the gravity
of the matters that have led us to conclude that her fitness to practise is impaired.

We were therefore satisfied that a caution order, even for the maximum period of five
years, was not a sufficient sanction in the circumstances of this case.

We then moved on to consider a conditions of practice order and concluded that

such an order, for a period of one year, would be both a practical and appropriate
course in this case.

The conditions we have decided upon are as follows:

1. In addition to your independent midwifery practice, you must notify the NMC
promptly of any professional appointment you accept and provide the contact
details of your employer in the UK or elsewhere.

2. At any time that you are employed, or otherwise providing professional

midwifery services, which require you to be registered with the NMC, you
must place yourself and remain under the supervision of a Supervisor of
Midwives who has relevant experience in high risk midwifery care.

3. You must inform the NMC of any formal disciplinary proceeding against you
from the date of this determination.

4. You must work with your Supervisor of Midwives to formulate a plan for
supported midwifery practice to address the following areas where your
practice has been found to be impaired.

i) Logistical Arrangements
 Before accepting clients, particularly those with high risk pregnancies, you
must ensure your Supervisor of Midwives approves logistical arrangements
including:

a) Distance or travel time from your base to your clients.

b) Contingency plans to provide midwifery support if you are unavailable, or

an emergency situation arises.

c) Monitoring of your workload, specifically the number of women for whom

you provide midwifery services, to ensure that safe standards of care can
be provided.

ii) Risk Assessment and Planning

To seek approval for your management plans for women with identifiable high
risk factors. These might include twin pregnancy and breech presentations at
term.

iii) Record Keeping

You must ensure that your Supervisor of Midwives assists you in reviewing
options for capturing sensitive issues in the maternity hand held records, such
as raised BMI, that may impact on care planning and provision. In reviewing
your record keeping you must discuss with your Supervisor of Midwives the
benefits and limitations of your shadow records.

5. For the avoidance of doubt, condition 4 applies equally to your existing clients.

6. You must meet with your Supervisor of Midwives (or their nominated deputy) on a
regular basis to discuss the requirements identified above. The frequency of your
meetings must be set by your Supervisor of Midwives or the Local Supervising
Authority (LSA) Midwifery Officer.

7. You are responsible for providing regular reports to the NMC every 3 months
regarding your compliance with these conditions.

8. You must inform the following parties that your registration is subject to the
conditions listed at 1-7:

• Any organisation or person employing or contracting with you to undertake

professional midwifery work.

• Any agency you are registered with or apply to be registered with (at the time
of application).

• Any prospective employer (at the time of employer)

Taking account of the public interest and Ms Montagu’s own interests we are
satisfied that this order represents a sufficient and proportionate sanction.
Reason for the interim order (if applicable)

The reasons for this decision are that such an order is necessary for the protection of
the public and otherwise in the public interest.

With regard to Ms Montagu's client who is due to give birth imminently, we see no
reason why she should not be told forthwith and that the rest of conditions should be
met as soon as is practicable.