A review and report by the Healthcare Safety Investigation Branch (HSIB) has said that three women who died under the care of the University Hospitals of Derby and Burton (UHDB) NHS Foundation Trust maternity unit may have survived if earlier recommendations had been implemented.
NHS Derby and Derbyshire commissioned HSIB to carry out a review at the request of the Hospital Trust. The Trust wanted an independent review to help identify lessons that could be drawn following a number of specific maternal incidents.
HSIB was asked to undertake a review of three maternal deaths and four maternal collapses between January 2021 to May 2022.
Review findings
The review made 26 findings, five recommendations and 10 safety prompts of areas for the Trust to improve safety.
It found that since the Trust had merged in 2018 policies, processes, guidelines and leadership had remained inconsistent and fragmented, and the Trust continues to experience significant staffing issues within its maternity service.
HSIB shared with the Trust an immediate concern in relation to the quality of the rapid reviews the Trust had undertaken following a patient safety event.
The review found that, at the point, the seven women experienced collapse or cardiac arrest, there were no identified common themes directly impacting on all outcomes.
Whilst the review did not find any common themes, it did find that there were opportunities to:
- Optimise process elements of the management of a massive obstetric haemorrhage.
- Better involve families in learning from incidents and decisions about their care.
- Improve the working relationships between some disciplines in the department, and address some reports of incivility from some senior team members.
- Conduct initial incident reviews more quickly.
- Implement learning from former and current incidents more thoroughly and responsively.
- Enhance holistic care given to women when they are discharged.
- Improve the clarity and consistency of guidance, and ensure documentation is completed more thoroughly.
Some of the key findings of the review were:
Process and leadership
Processes and leadership at UHDB NHS Foundation Trust had been inconsistent and fragmented, and said that “robust action planning and prompt addressing of the learning” from previous recommendations following other investigations “may have had an impact on the outcome for the women who received care during the seven events included in this thematic review.”
Staffing issues
The Trust has significant midwifery staffing gaps, which impacted communication and the experience of the women but did not directly impact the events included as part of the review.
Behaviours
Substantial evidence of poor behaviours, bullying and hierarchical culture, especially within the obstetric team, was found. The report said:
“There are significant issues that the trust need to address, particularly around governance and leadership.”
Documentation
In addition, areas of documentation were found to be incomplete or missing altogether. The investigation noted a theme of no designated scribe for the emergency, which meant key areas of care were not clearly identifiable.
Communication
There were examples of communication which led to non-engagement and an unwillingness to involve the women and their families in decisions about their care. There was also limited evidence of follow-up care for the women or their families once they were discharged.
Previous Learning: Perhaps most concerningly, the review noted that learning from previous HSIB safety recommendations had not been fully implemented. Some staff training was out of date, the governance processes were not robust and there was limited evidence historically of multi-professional review.
Ultimately, it was found by HSIB that robust action planning and prompt addressing of the learning from the previous recommendations which had been made may have had an impact on the outcome for the women who received care during the seven events which were under review.
You can read the detail of the report here.
Dr James Crampton, UHDB Executive Medical Director, said:
“The seven incidents have had a longstanding impact on the families involved, so it was paramount to us to ensure we had utilised every possible opportunity for further learning and why we proactively requested this independent review.
Although the review did not find any common themes that impacted on the outcomes for all the women involved, there has been learning for us an organisation which we have taken very seriously, and the recommendations are invaluable in helping us further improve safety and the experience of women under our care.
We have already addressed the report’s immediate recommendations, including refining our existing major haemorrhage guidance and enhancing our emergency bleep process, and have put a comprehensive plan in place to rapidly deliver all other initial actions within the next three months.”
Comment
At a time when maternity services across England have been under such scrutiny, it is saddening to see that another Trust is not providing the level of care and service that mothers, babies and families should expect.
It is reassuring to see that this report into Derby maternity services came about at the request of the Trust itself in a clear effort to learn and prevent. However, it has to be noted that prior to the events forming the basis of this review, the Trust had already been provided with recommendations and safety prompts by HSIB before, and yet still improvements had not been made.
With the safety of patients at risk in such a significant way, the Trust has a lot of work to do following this report to turn things around and rebuild trust with local mothers and families who will understandably have questions as to where they can feel safe to deliver their babies.
How can we help?
Danielle Young is a Legal Director in our Medical Negligence team, which has been ranked in tier one by the independently researched publication, The Legal 500.
If you have any questions in relation to the subjects discussed in this article, then please get in touch with Danielle or another member of the team in Derby, Leicester, or Nottingham on 0800 024 1976 or via our online form.
Contact us