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External review at top hospital over four maternal deaths

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An external review is being carried out into four maternal deaths at a leading London hospital trust.

A King’s College Hospital Foundation Trust spokeswoman said: “Sadly, four women died at our Denmark Hill site within 42 days of childbirth in 2015-16. Two of the women did not give birth at Kings.

“Patient safety is our top priority and we immediately conducted internal reviews into each case,” she said. “Our findings did not establish a link between the cases.

“For added assurance we called for each case to be independently reviewed. We fully complied with the external reviews and currently await their outcomes.” King’s said the internal reviews included external representation on them. It has not said when it expects the external review to be completed,” she told Nursing Times’ sister title Health Service Journal.

One of the four women died from a brain injury caused by lack of oxygen following a post-partum haemorrhage after a caesarean. An inquest held last month found doctors at King’s College had failed to give Abimbola Babatola, 39, a blood transfusion.

The coroner concluded Ms Babatola’s death was a result of natural causes, but that a failure to give Ms Babatola a blood transfusion “amounted to neglect”, according to a local newspaper report.

Maternal deaths are generally rare; there were 46 maternal deaths in 2014 out of 695,233 deliveries.

King’s College Hospital has a well respected maternity department. It has been highly rated under the national “friends and family test” of patient experience, and hosts the renowned Harris Birthright Centre, a leading clinical unit and research centre for the assessment and treatment of unborn babies.

Despite caring for some of the most complex pregnancies in the UK, the stillbirth rate at King’s is low: 4.51/1,000, compared to a national average of 4.6/1,000.

However, a September 2015 Care Quality Commission report found staffing levels “inhibited the provision of optimum care” to mothers in maternity at Denmark Hill.

Increased demand for maternity inpatient services at King’s College Hospital meant that staff were “encountering significant pressures with the post-natal ward often operating at full capacity effectively resulting in ‘gridlock’”, the report found.

The CCQ rated Denmark Hill’s maternity unit as good for being caring and effective, but said it “requires improvement” overall.

Homerton University Hospital Foundation trust in Hackney, east London, was the last trust to launch an external investigation over a disproportionately high number of maternal deaths.

Four mothers died at Homerton Hospital between July 2013 and April 2014. An independent investigation, completed in February 2015, found no failings in the standard of maternity care at Homerton Hospital although there were some recommendations for improvement. A fifth woman died following a birth at Homerton January 2015.

  • This story was updated at 10.30am on 27 September to add the detail that King’s internal reviews included external representation. It was also updated at 2.14pm after Kings provided new information stating that two of the women did not give birth at Kings.
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