This investigation by the Healthcare Commission examined the cases of ten women who died during pregnancy or within 42 days of delivery at Northwick Park Hospital, North West London Hospitals NHS Trust, between April 2002 and April 2005. This number of maternal deaths was significantly higher statistically when compared with other trusts that serve similar populations.
The report highlights the following key findings:
- The maternity service was offering care to women whose pregnancies represented a high risk, but did not have the necessary systems or staff with the appropriate skills in place to manage such cases.
- There was a lack of input from consultants at crucial times, and there was an over reliance on junior staff to manage complex and difficult cases with little guidance or support.
- Consultant obstetricians did not routinely carry out ward rounds when they were responsible for overseeing care in the labour ward and the teamwork between midwives and obstetricians was not as effective as it should have been. Therefore, there was no adequate mechanism in place for staff to discuss concerns that they may have had about the women.
- There was an excessive reliance on the use of locum and agency staff, who did not always receive the necessary guidance or support.
- Deficiencies in the management structures also contributed to the poor quality of care the women received, for example midwives were expected to manage a busy delivery suite that was reliant on agency and locum staff, with at times, little professional or managerial support. Around the time of the first deaths the midwives received little professional support from the supervisors of midwives.
- In the majority of cases the women attended their hospital and GP antenatal appointments and sought help when they felt unwell. Yet despite this, in a number of the cases, clinical staff failed to recognise and respond to the severity of the condition of the women, thereby reducing the chances of survival of the women. In some of the cases there were minor deficiencies in care which, in isolation, may not have had such a dramatic impact, but when occurring together had serious consequences for the health of the women concerned.
- The anaesthetic staff involved in the care of the women responded well, often in difficult circumstances.
- The haematology department responded efficiently in providing the necessary, and at times large, volumes of blood and blood products.
- In two of the cases there was an absence of documentation for surgical procedures that were carried out by the obstetric staff and in
- one case there was an absence of contemporaneous documentation.
An independent review of serious untoward incidents and clinical governance systems within maternity services at Northwick Park Hospital (16 September 2008)
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