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East London maternity unit judged 'inadequate' for safety

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Regulators have told Homerton University Hospital NHS Foundation Trust to improve its maternity services following an inspection triggered by the deaths of five mothers over 18 months.

The Care Quality Commission has concluded that maternity services at the hospital are “inadequate” for safety and “require improvement” overall.

“We found that some staff showed a limited understanding of the serious incidents and were not aware of the learning or actions taken following the five deaths”

Edward Baker

Between July 2013 and January 2015 there were five maternal deaths at the hospital. Separate reviews into these deaths, by City and Hackney Clinical Commissioning Group and NHS England, found no links between them.   

However, concerns rasied by the CCG sparked the CQC into making an unannounced inspection of the maternity service in March.

In their report, published today, the inspectors found that no midwives they spoke with were aware of the five deaths.

Incidents were not always reported despite systems in place to encourage reporting, said the inspectors, and there were “unacceptable” levels of serious incidents and never events.

The response to reported incidents was slow, which meant “continued potential risks to mothers and their babies”.

In addition, the standards of cleaning in all areas of the maternity service were “poor”, and resuscitation and emergency equipment was not consistently checked to make sure it was ready for use.

Drugs were not administered or stored safely, and unauthorised people could get access to drugs, noted the CQC.

The inspectors also found midwifery staffing levels were below the recommended guidelines and some shifts on the labour suite were staffed predominately by bank and agency staff.

Meanwhile, the performance of the unit was below national targets for sepsis, post-partum haemorrhage and the number of births by normal delivery, and there was “limited evidence” of action being taken to address this.

The inspection team found that the majority of midwives did not understand the Mental Capacity Act and their responsibilities in this area.

Despite this, most women and their partners were positive about the care they received and said they received the emotional support they required.

In addition, women and babies’ nutritional, hydration and pain relief needs were managed and many of the clinical guidelines had been reviewed and were up to date.

“A significant amount of review and much work has taken place within the department to resolve the concerns highlighted by the inspectors”

Tracey Fletcher

Trust chief executive Tracey Fletcher said: “We always welcome scrutiny from our regulators and our maternity department was scrutinised intensely during the visits made by CQC inspectors in March.

“Since that time, a significant amount of review and much work has taken place within the department to resolve the concerns highlighted by the inspectors and importantly, to satisfy ourselves that the services we are providing to women are safe,” she added. 

Edward Baker, the CQC’s deputy chief inspector of hospitals, said he was concerned that the trust had not “thoroughly reflected” on the maternal deaths in recent years.

He added: “We found that while the trust has systems in place for investigating serious incidents and deaths, these investigations were limited in scope and the resulting actions were often delayed and not fully embedded into practice.

“We found that some staff showed a limited understanding of the serious incidents and were not aware of the learning or actions taken following the five deaths,” he said.

He added: “Following our inspection, we told Homerton University Hospital Foundation Trust that it must take urgent action to address our immediate concerns and to ensure that there are lasting improvements.”

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