Review of maternity care at University Hospitals of Derby and Burton

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Over the last year, a number of investigations have taken place into maternity care in various NHS Trusts, such as the Kirkup Independent Inquiry and The Ockenden Maternity Review. These reviews often looked at the care provided to hundreds of families and were sadly not the first time this has happened in the UK. A summary of various maternal scandals in the UK over the past decade can also be found here.

As a result of these recent national reports, University Hospitals of Derby and Burton (UHDB) commissioned an independent review into seven maternity incidents which took place at Royal Derby Hospital between January 2021 and May 2022.  The investigation was carried out by the Healthcare Safety Investigation Branch (HSIB).

The findings of the HSIB report highlights the ongoing need for improvement in maternity care in Derby and may mean that other families who have received similar care in Derby or elsewhere have questions that they need support finding the answers to.

The maternity incidents

The seven maternity incidents being investigated related to the deaths of three mothers, including one baby who also died, and four cases of mothers ‘collapsing’ (i.e. suffering serious complications) during their maternity care.  HSIB also reviewed the wider practices within the obstetric unit at the Trust.

These incidents had been individually investigated but it was felt that a wider review was needed to identify all possible lessons for the Trust across their maternity care generally.

The fact that the Trust took this step independently shows that the recent reports are starting to have a positive impact on maternity care in Trusts all over the country.  Taking this proactive step to identify and attempt to fix any problems within their care means that future scandals impacting 100s of families can hopefully be avoided.

The findings of the report

Although there was no single problem that was identified to have contributed to all of the maternity incidents at Royal Derby Hospital, there were a number of recommendations, safety prompts and findings that were listed in the report.  One of the main issues reported was in relation to the number of staff on duty at all levels. Although this didn’t contribute to the failings identified in the seven incidents investigated, it did impact on the overall experience of women and families using the Hospital.  This issue also appears to go all the way up to the governance and leadership of the maternity team (which the report described as ‘fragmented’) and HSIB recommends that the Trust should address it.

The report found some key areas for learning which included:

  • Improving management of “massive obstetric haemorrhage” cases, i.e. where a mother loses more than 2.5 litres of blood. This included a) having two emergency numbers rather than just one resulting in confusion for staff regarding which emergency number to use to call for help, and b) improving processes to declare a haemorrhage and ensure the full dedicated team is contacted quickly and clearly;
  • Improving communication – ensuring that families are involved in the learning from individual incidents and decisions about their care, and that this continues after they have been discharged. There were also issues identified with the way members of staff spoke to each other, particularly between obstetricians and midwives;
  • Carrying out reviews more quickly, involving the family, and then making sure the learning is implemented more thoroughly after an incident;
  • Improving working relationships between different disciplines (e.g doctors and midwives) in the obstetric maternity department;
  • Ensuring guidelines are clear so staff know what steps need to be taken in an emergency and that all paperwork is fully completed; and
  • Improving the holistic care given to women when they are discharged. As above, this includes improving communication with these woman to prevent them feeling abandoned and making sure they are kept up to date even after leaving the hospital.

The impact of the report

The Executive Medical Director of the Trust has acknowledged the key lessons from the investigation and has released a statement to say that the report’s immediate recommendations have already been addressed.  They also have plans to address the remaining recommendations by the end of May 2023.

The Trust is implementing changes such as better access to on-call registrars and ensuring that staffing levels are always appropriate.  They are also looking at making sure their training is improved for staff members to make sure that there is better note keeping and that any emergencies are better managed.

Overall, whilst the report did identify several areas of concern, good care was also recognised (such as a generally ‘kind and compassionate’ culture) and the Trust appears to have taken all the recommendations very seriously.  This should help to improve maternity safety going forward and help reduce mothers and babes from coming to avoidable harm.

Are you considering whether you need legal support?

A medical negligence claim is an opportunity for families to get answers in individual cases and to encourage learning at the hospital to make sure the same mistakes aren’t made again.

If you have any concerns about whether something went wrong during your maternity care, before or after birth, Enable Law can help to get some of the answers you need.  We recognise the devastating impact that a baby’s death or injury to mum during labour has. We will work with you to determine what happened, whether the care provided was substandard and are committed to helping you get the answers you need.

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