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Common threads in maternity deaths across the NHS

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Maternity services at yet another NHS hospital trust have come under scrutiny with an inquest due shortly into the death of a baby boy in Doncaster.

The case concerns a low-risk pregnancy where the mother ended up being induced. The family believe their baby died from multiple skull fractures after two forceps attempts and an eventual C-section delivery.

The Healthcare Safety Investigation Branch had drawn up a report into the case and   Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust said an inquest would be held soon.
Shoosmiths, which has acted for a number of women whose pregnancies ended in tragedy, and is continuing to investigate trusts on behalf of other clients, said this is the latest in a series of tragedies in maternity units and believes there are common threads about lessons not being learned and mistakes acted upon.

Amy Greaves, an experienced medical negligence solicitor at the Birmingham office of Shoosmiths, said there also appeared to be a trend in failing to assess the maternal risk and delays in inducing deliveries which could be indicative of a nationwide problem and not limited to particular hospital trusts. She said:

“A focus on patient safety is so important for mothers and babies but there are concerns that too many hospitals are not getting this right.

“Common themes in cases we see are about mothers being registered as low risk when they are actually higher risk. We also still find that vaginal births are wrongly considered ‘natural’ or better when in some cases a surgical delivery is safer. We have a number of clients who have said their requests for a C-section have been ignored until the very last moment. This increases the risk to both baby and mother.

“Sadly, we regularly see a failure to appropriately review the CTG leading to poor outcomes on delivery. More training on interpretation of Cardiotocography (CTG) scans that monitor the baby’s heart beat are needed.”

Last month (July) the Safety of Maternity Services in England report was published setting out steps which need to be taken in order to improve the safety of maternity services in England after the 2015 Kirkup inquiry found ‘serious and shocking’ failures at the Morecambe Bay NHS Foundation Trust 2004-2013.

Major concerns were raised later at about Shrewsbury and Telford Hospital NHS Trust and the East Kent Hospitals University NHS Foundation Trust, where scores of babies and mothers sustained serious injuries or died.

Also last month, a report by the House of Common’s Health Select Committee into the safety of childbirth care found that there are 1,000 preventable baby deaths every year in England, partly because of a culture of shifting blame and not being open, with lessons not learned.

Prof Ted Baker, the Care Quality Commission’s chief inspector of hospitals, told the committee’s inquiry that enduring problems included “a defensive culture, dysfunctional teams and poor quality investigations without learning taking place.”

Amy Greaves, said:

“A blame culture, one where mistakes are hidden rather than brought into the open is simply just putting the problem off to another day as eventually the truth about what happened comes out. Often this can be too late for any affective remedial treatment and leaves mothers with a sense of mis trust which negatively impacts on future pregnancies.”

Maternity services at both the hospitals run by the Yorkshire trust are currently rated as ‘Requires Improvement’ by the hospital regulator the Care Quality Commission (CQC).

In the past few months, it has been reported that a number of maternity wards have been downgraded to “inadequate,” with Northwick Park Hospital, East Suffolk, Sheffield Teaching Hospital NHS Foundation Trust and North Essex Foundation Trust all included in recent CQC inspections.

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