Maternity unit blamed24th August 2006
The Healthcare Commission has published an investigation report into the deaths of ten women who gave birth at Northwick Park Hospital, West London.
The inspectorate is renewing its call for NHS trusts to check that they have robust systems for monitoring the safety of maternity units.
All ten women died during pregnancy or within 42 days of giving birth between April 2002 and April 2005, a significantly higher number of deaths than the national average for maternity. The hospital serves half a million people in Brent and Harrow, two boroughs with large black and minority ethnic populations. Of the women who died, six were Asian, two African, one Afro-Caribbean and one European.
The causes of death varied. Strokes following pre-eclampsia were the cause in three cases, with bleeding after giving birth in four other cases. One woman died of a cardiac arrest, and another of viral encephalitis.
In April last year, the Commission recommended that the Government place North West London Hospitals NHS Trust under special measures, and called in an external team to safeguard women at Northwick Park Hospital’s maternity unit.
The Commission criticises the quality of care given by the Trust in nine out of the ten cases.
Common factors in the deaths include:
- insufficient input from a consultant or a senior midwife (in five cases), with difficult decisions often left to junior staff.
- failure in a number of cases to recognise and respond quickly where a woman’s condition changed unexpectedly
- inadequate resources to deal with high-risk cases: too few consultant obstetricians and midwives; not enough dedicated theatre staff; a reliance on agency and locum staff without adequate managerial or professional support; and a lack of a dedicated high dependency unit
- a working culture that led to poor working practices and resulted in poor quality of care
- failure to learn lessons on the unit; the Trust took action following the deaths but the working environment was such that mistakes were repeated
- failure by the Trust’s board to appreciate the seriousness of the situation – the board was aware of the high number of deaths, and should have acted sooner to rectify problems.
The HCC did have some praise for the Trust; Anaesthetic staff and the haematology department, which provided blood for the patients, were praised for responding well under difficult circumstances.
The Commission says there have been significant improvements in the maternity services provided there, although the Trust remains under special measures. Three additional consultants and 20 more midwives and the inspectorate also believes there is now better team working between consultants and the obstetric staff, and between the obstetric staff and midwives.
Commission Chairman Sir Ian Kennedy last year urged NHS trusts to raise standards in their maternity services to those of the best. He said the overall root cause of poor performance is often weak managerial or clinical leadership which can leave problems unidentified or unresolved.
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