Maternity unit death 'lessons not learned'

High-risk women at a maternity unit were not monitored closely enough and there was a "lack of learning" from a mother's death, inspectors found.

A Care Qualtiy Commission (CQC) report rated the unit at Basildon University Hospital as inadequate with "failings" found in six other serious cases. Inspectors carried out unannounced checks in June after a whistleblower voiced fears about patient safety.

The unit was criticised following the deaths of baby Ennis Pecaku in September 2018 and mother Gabriela Pintilie, 36, in February 2019.

The CQC previously carried out an inspection of the department the month Mrs Pintilie died and said the unit, which had once been rated outstanding, required improvement. Inspectors returned for the surprise "focused" inspection after being contacted by an anonymous whistleblower. The report found babies were born in a poor condition and then transferred for cooling therapy, which can be offered for newborn babies with brain injury caused by oxygen shortage during birth.

During their visit, inspectors found:

• High-risk women giving birth in a low-risk area.
• Not enough staff with the right skills and experience.
• "Dysfunctional" working between midwives, doctors and consultants, which had an impact on the "increased number of safety incidents reported".
• Concerns over foetal heart monitoring.
• Women being referred to by room numbers instead of their names. 
• A "lack of response by consultants to emergencies" resulting in delays

The CQC also referred to issues relating to the death of Mrs Pintilie, who was not named in the report, and said five serious incidents "identified the same failings of care".

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Source: BBC News, 18 August 2020

"This demonstrated there had been a lack of learning from previous incidents and actions put in place were not embedded."