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Written on 1st March 2023 by Susan Brown

A review by HSIB at Royal Derby Hospital has concluded that failure to act on more than 80 previous HSIB recommendations may have affected the outcomes for seven women who died or collapsed whilst having their babies.

The healthcare watchdog, HSIB, was commissioned by the NHS Derby and Derbyshire Integrated Care Board (ICB) to carry out the thematic review after one mother died and then four other women suffered collapses or cardiac arrests during childbirth over a period of eight weeks. HSIB’s review also included two additional maternal deaths which had previously occurred at the trust.  All the women were booked under the NHS trust’s care for hospital births and all the babies were delivered by caesarean sections, including one by resuscitative hysterotomy in the woman’s own home.  Three of the seven women suffered major/massive obstetric haemorrhages (MOH).

What is maternal death?

Maternal death is the death of a mother during pregnancy or up to six weeks after the pregnancy ends, due to  something directly related to or aggravated by the pregnancy or its management.

What is maternal collapse?

Maternal collapse is an acute (sudden), life-threatening event involving the cardiorespiratory (heart and breathing) systems and/or central nervous system (brain and spinal cord) which causes the mother to lose consciousness.  Maternal collapse has many different causes and can occur at any time during the pregnancy and up to six weeks after the birth. It is life-threatening and if not treated immediately with effective resuscitation it can cause cardiac arrest and death.

The maternal experiences

The report does not focus directly on the care of the women as these have been investigated elsewhere. Of those who died, one had a cardiac arrest at home, where her baby was delivered by resuscitative hysterotomy. HSIB noted that on her emergency transfer to hospital urgent review by a senior doctor was delayed because A&E staff did not know how to make an obstetric emergency call. Another woman with placenta praevia and vaginal bleeding died from cardiac arrest after an emergency caesarean birth, following delays in giving her blood for major obstetric haemorrhage (MOH).  A third woman died immediately after an elective caesarean section from cardiac arrest.

Of the women who survived, one had a cardiac arrest after a lengthy, unsuccessful induction of labour and emergency caesarean birth. Another suffered a major obstetric haemorrhage after a difficult breech birth by caesarean. Another suffered neurological injury after maternal collapse and seizures during augmentation (boosting) of labour during her sixth pregnancy. Another woman suffered a cardiac arrest during an elective caesarean birth and needed further surgery for extensive internal injury caused during her resuscitation by CPR. Her pregnancy was complicated by her medical history of psoriatic arthropathy (a type of arthritis with inflammation), gestational diabetes and positive Covid-19 at the time of the birth.

What were the findings of HSIB’s review at Royal Derby Hospital?

HSIB did not find any single theme which directly affected the outcome for these women, but identified areas of concern within the hospital’s maternity service which may have contributed to one or more of the maternal safety events.

General issues included:

  • a long period of fragmented and changing leadership since the trust’s two maternity units had merged in 2018;
  • guidance which was inconsistent and difficult to navigate;
  • staffing shortages arising from sickness, difficulties with staff retention and recruitment, including a lack of anaesthetic consultants affecting operation lists and additional theatre lists needed to catch up after covid;
  • inaccurate or missing documentation relating to giving medications, but also, crucially, in relation to care given in emergency situations;
  • bookings for midwifery training were recorded as 100% compliant, however both medical and midwifery staff told HSIB that their training was out of date because they had been taken off booked training days to carry out clinical duties.  Following the review, the trust advised HSIB that it will not be reporting 100% compliance in this area to NHS Resolution for the purposes of the Maternity Incentive Scheme’s CNST requirements.

HSIB’s review found critical areas that need prompt action to improve safety. These related to major/massive obstetric haemorrhage (MOH), communication and reviews.

  • Obstetric haemorrhage

Obstetric haemorrhage is bleeding in pregnancy or during or after childbirth. It is the leading cause of maternal death and morbidity (ill health) worldwide, and a significant cause of maternal death in the UK. However, according to MBRRACE-UK, although major obstetric haemorrhage (MOH) is often seen in labour wards in the UK, with correct care it should usually be preventable.

HSIB found that the hospital needed to improve its processes for managing MOH. This included improving the process for calling for help and making sure that the correct staff were present to provide emergency care for a woman with MOH.

HSIB issued safety recommendations requiring the trust to ensure that there is a clear process for declaring an MOH, and ensure that emergency calls trigger further notifications which alert the necessary staff, as defined by RCOG guidance, to provide the woman receives safe and timely emergency care. HSIB also recommended the trust used the 2222 call for all emergency calls in accordance with national guidance.

  • Communication

HSIB found that staff faced barriers to effective communication, mainly from hierarchy within the different specialities of staff involved in the maternity teams. There was a kind and compassionate culture amongst front-line staff, but many staff experienced intimidation, bullying, incivility, poor behaviours and poor role modelling from the senior (particularly obstetric) team. Obstetric consultants often behaved unprofessionally. Attempts to escalate or improve the behaviour were met with hostility and threats, so that unprofessional behaviour had become part of the culture.  Senior staff were not available or visible within the maternity unit.

Communication failures included not engaging or involving women and their families in decisions about their care. Following discharge from hospital, even after these tragic or life-threatening events, women and/or their families felt abandoned, with follow up communication that was described as “unbelievably poor”.

  • Maternity safety reviews

At the beginning of the thematic review, HSIB raised their immediate concerns with the ICB and the NHS trust about some of the rapid reviews that the trust had carried out after the maternity safety events. HSIB found that many of these ‘72-hour reports’ were not fit for purpose. They failed to identify any learning or actions, and there was no evidence that their reviews involved the patient or family or had been shared.

HSIB learned during the review that the trust’s maternity safety review process was closed, inconsistent and erratic. Staff who had been involved in the care were not invited to attend the reviews, and the obstetric team were not open to other specialities and made assumptions on their behalf.

Trust’s failure to learn from 82 previous HSIB recommendations may have affected the outcomes for these women

HSIB found that the trust had failed to take action or implement up to 82 previous safety recommendations that HSIB has issued to the trust in maternity investigation reports between April 2019 and November 2022.  

Whilst many of the previous recommendations do not specifically apply to the seven women whose care was under review, those that involved issues which HSIB say could have made a difference included:

  • improving situational awareness amongst delivery suite staff to help manage complex clinical situations safely;
  • improving multidisciplinary working relationships and communication;
  • 24-hr access to operating theatres;
  • having an overview (helicopter view) of the patient’s entire situation in emergency situations;
  • escalation of clinical concerns, including when incorrect decisions or interventions are taking place;
  • involvement and oversight by senior obstetricians, especially for mothers with known risk factors;
  • initiating MOH protocols as soon as a mother experiences significant blood loss;
  • early involvement of senior members of the perinatal team in emergency situations.

HSIB concluded that robust action planning and prompt learning from these previous recommendations may have had an impact on the outcome for these seven women whose maternity care prompted this thematic review.

If you have been seriously injured as a result of medical negligence, or have been contacted by HSIB/HSSIB, MNSI or NHS Resolution following your hospital care, you can speak to one of our experienced solicitors, free and confidentially, for advice on how to respond or make a claim, by contacting us here.