Midwife who put 'gone for a break' sign on colleague while bleeding mum waited 37 minutes is struck off after baby died

Published 15 October 2026, 15:41

• An NMC Fitness to Practise Committee panel struck Kathryn Laura Duignan off the nursing register after finding she failed to triage Patient A on arrival at Kings Mill Hospital.
• Patient A — 41 weeks pregnant, in a wheelchair, visibly in pain and bleeding heavily — was left unassessed for 37 minutes while her family shouted for help three times.
• Baby A died two days after an emergency caesarean, with a coroner ruling in July 2024 that earlier delivery 'would on balance have resulted in survival.'

A midwife who placed a handwritten "gone for a break, back in 30" sign on a colleague sitting at the triage desk — while a bleeding, 41-weeks-pregnant woman sat unassessed in a nearby room for 37 minutes — has been struck off the nursing register after the baby died two days later.

An NMC Fitness to Practise Committee panel, chaired by Dave Lancaster, struck Kathryn Laura Duignan off the register following a hearing held between 28 September and 9 October 2026 in London.

The panel found all four charges against her proved: failing to triage Patient A in a timely manner, failing to respond to repeated calls for help from Patient A's family, placing the sign on Colleague B at the triage desk, and — most gravely — that her conduct resulted in the loss of a chance of survival for Baby A.

Duignan was working as a Band 7 maternity coordinator at Kings Mill Hospital in Nottinghamshire on the night of 13 September 2023, the most senior midwife on duty in the triage department.

Patient A, a first-time mother at 41 weeks gestation, arrived at the hospital at approximately 1:05am.

She was in a wheelchair — provided by a security guard because she was in such severe pain she could not walk — visibly distressed, and bleeding heavily.

Before Patient A arrived, telephone triage midwife Miss Smedley had verbally informed both Duignan and colleague Mrs Wood that Patient A was returning to the hospital due to vaginal bleeding.

The panel found that when Patient A arrived, Duignan was sitting at the midwives' station alongside Mrs Wood, and that both of them would have seen her partner and heard him state that she was experiencing bleeding rather than labour.

Patient A was moved to a side room by Mrs Wood, who carried out no assessment of her.

The hospital's own protocol required triage within 15 minutes, with escalation if that could not be achieved.

The panel said: "No good reason has ever been advanced as to why Patient A was left for 37 minutes. At the time of Patient A's arrival at 01:05 neither Mrs Wood nor Miss Duignan were occupied with other patients as there were no other patients in triage and none were expected."

From inside the room, Patient A's family called out for help repeatedly.

Patient A said in her written statement dated 6 January 2025: "I recall my mum and Person A shouting for help three times."

Person B, Patient A's mother, said in her witness statement dated 7 January 2025: "We could clearly hear their conversation so I believe they should have heard my multiple calls for help. I can't help but feel that they chose to ignore it. When no one else came in, I shouted for help again and I recall seeing the clock showing 01:31."

During this same period, Duignan acknowledged in a statement she gave as a Trust witness during the investigation, dated 30 November 2023, that she had written a sign and attached it to Colleague B — identified as Glenys — while Glenys was seated at the triage desk where members of the public could see her.

When asked what the sign said, she said: "It might have said 'Back in 30-minutes', I don't remember the exact detail."

The panel found this conduct was "indicative of her failure to prioritise patient care and fully engage in work related matters."

At 1:42am, midwife Sharon Anderson entered the triage ward and asked whether anyone had triaged Patient A.

On being told no, she triaged Patient A herself.

A medical emergency was immediately apparent.

Patient A underwent a category one emergency caesarean section at 2:02am.

Baby A's death on 15 September 2023 was the result of hypoxic ischaemic encephalopathy, which had been brought on by a placental abruption.

A Coroner's inquest in July 2024 returned a narrative verdict finding that neglect contributed to Baby A's death.

The Coroner's Judgment, dated 5 July 2024, said that Patient A "was not seen for 37 minutes on arrival at the Triage unit...when she was in pain and with significant vaginal bleeding. Had she been seen on arrival as she should have been, would have been delivered by an emergency Category 1 caesarean section, likely by 01.25, certainly by 01.35, instead of at 02.02 hours as occurred. Had he been delivered at either of these earlier times, he would on balance have survived."

The panel accepted the Coroner's conclusions in full and determined that had Duignan ensured Patient A was triaged at or shortly after her 1:05am arrival, Baby A would have been born shortly after 1:25am.

The panel said: "Miss Duignan's inactions were not a momentary lapse. There was a period of 37 minutes where she could and should have ensured that Patient A was triaged but she did not do so."

Duignan was absent from the hearing and had no representation, having disengaged from the NMC and sought voluntary removal from the register by agreement, a request that was denied.

The panel considered and rejected every lesser sanction in turn, concluding that "nothing short of a striking-off order would be sufficient and proportionate in this case and this is the only sanction which would be sufficient to protect the public."

The panel additionally issued an interim suspension order lasting 18 months, which is designed to remain in place during the 28-day window for appeal that must elapse before the striking-off order comes into force.