Sunday, August 27, 2006


They're not fussy: Mothers, kids, who cares? Everybody still gets their salary and nobody is ever penalized significantly

Ten women died during childbirth or shortly afterwards in a hospital that suffered from a lack of clinical leadership, a poor working culture and an overloaded maternity unit. The deaths, at Northwick Park Hospital in northwest London, occurred between April 2002 and April 2005, and involved women giving birth or within 42 days of birth. The Healthcare Commission publishes a detailed account today of each of the deaths.

In April 2005 the commission recommended "special measures" to restore good standards at the hospital, which included calling in an outside team to safeguard women. In today's report it says that these measures are working. But the report lays out in painful detail what can happen in a maternity unit that has inadequate systems. In nine out of the ten cases, the report says, there are grounds for criticism. It summarises these as:

* Insufficient input from a consultant or a senior midwife (in five cases), with difficult decisions often left to junior staff.

* Failure to recognise and respond quickly when a woman's condition changed unexpectedly.

* Inadequate resources to deal with high-risk cases: there were too few consultant obstetricians and midwives; not enough dedicated theatre staff; a reliance on agency and locum staff without adequate support; and a lack of a dedicated high-dependency unit.

* A culture that led to poor working practices.

* Failure to learn lessons on the unit, leading to mistakes being repeated.

* Failure by the North West London Hospitals NHS Trust board to appreciate the seriousness of the situation. It was aware of the number of deaths, and should have acted sooner.

Two aspects of the service are singled out for praise. The report says the anaesthetists and the haematology department, which provided blood for the patients, responded well under difficult circumstances.

Of the women who died, six were Asian, two African, one Afro-Caribbean and one European. The hospital serves half a million people in Brent and Harrow, two boroughs with large black and minority ethnic populations.

The causes of death varied. Strokes following pre-eclampsia (very high blood pressure) were the cause in three cases, with bleeding after giving birth in four other cases. One women died of viral encephalitis, one of a cardiac arrest.

The hospital investigated the deaths from a predominantly legal point of view, as if seeking to defend itself, the report says. Common factors were not found, but the commission says that they did exist and should have been identified.

Marcia Fry, the commission's head of operational development, said: "We hope this report gives some answers to the families involved. "We expect trusts across the country to read this report. Most women give birth safely. But there are risks and the NHS must ensure it does all it can to reduce them. There can be no excuse for failing to learn the lessons from tragedies of this kind." Since April 2005 three additional consultants and 20 more midwives have been recruited. The inspectorate also believes there is a better team working among consultants, obstetric staff and midwives.


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