It’s a very sad case but it is absolutely not the midwifes fault. A baby will pull back if their airway is compressed. If this baby really did suffocate while feeding it must have been held against the breast. It is common sense to not cover a baby’s airway even without being told. Should midwives also be giving a big list of things not to do, don’t drown your baby, don’t leave your baby alone, don’t let you baby play with razor blades. This is obvious stuff that doesn’t need saying surely!
As for observing the feed, a baby can feed for up to 1 hour, it isn’t practical to observe the entire feed after making sure baby is latched on ok. And what’s to say this couldn’t happen in the second feed, or the 10th? It takes a while to establish and become confident breastfeeding. Should a midwife on the ward, caring for 10 new mothers be observing all their feeds that can be an hour long, every 3 hours? It’s impososble! Should we be sending a live in midwife to observe all feeds at home, observe the first bath to make sure you don’t drown them, observe the first trip out to make sure you’re putting them in the Oran correctly, observe the first time you drive with them. At some point parental responsibility has to kick in, you are responsible for that baby and you’ve had 9 months to prepare and learn. If you’re not sure of course ask but you can’t blame someone else for not telling you that covering a baby’s airway is dangerous!