The entire board of the Channel Island’s health department have resigned following the death of a baby that called into question the quality of midwife supervision on Guernsey.
The board of Guernsey’s Health and Social Services Department said it was “committed” to investigating the circumstances that led to “the tragic death of a new born baby earlier this year”.
As a result, professional regulators carried out a review of Guernsey’s midwifery supervision arrangements last week and a second, wide ranging review into maternity services is planned for the future.
“As the board is accountable, this is best demonstrated through our resignations”
However, the board said its accountability for the incident – the precise details of which have not been released – would be “best demonstrated” through resigning.
In a statement released on Friday, its five members offered their “heartfelt condolences” to the family who lost their baby – the identity of whom has remained private at their request – and said the matter was being taken “extremely seriously”.
“We are investigating what happened with the greatest care and scrutiny and with the assistance of independent external experts,” the statement said.
“We are also focused on doing everything possible to minimise the risk of the circumstances that led to this tragic incident ever happening again,” it added.
An extra-ordinary review into the quality of midwifery supervision in Guernsey took place last week, from Wednesday to Friday. The Nursing and Midwifery Council will publish a report on the review’s findings, which the health department will then be required to act on.
The department also said it was liaising with the NMC and the General Medical Council on terms of reference for an overarching review of maternity, obstetric and paediatric services in the Bailiwick [of Guernsey].
In addition, the board said it had taken some “immediate precautionary actions” to boost midwife staffing levels and clinical leadership in local maternity services (see box below for details).
Mark Dorey, minister for the health and social services department, said: “Ideally the board would have liked to continue its work with the staff to ensure significant relevant improvements were made to systems of governance, supervision and regulation. But under the circumstances, the board… have decided to resign.
“Principally, as politicians, we are responsible for strategy, policy and to be accountable for the department,” he said.
“Recent reports on midwifery did not identify any significant problems. However as the board is accountable, this is best demonstrated through our resignations,” he added.
In a statement, the NMC said it had recently been made aware of issues around the supervision of midwives in Guernsey by the Local Supervising Authority.
Jackie Smith, NMC chief executive and registrar, said: “We are deeply concerned by reports we have received about the quality of supervision of midwives in Guernsey and what affect that may have had on public safety.”
She said the extra-ordinary review had been commissioned to “seek assurances” about the quality of midwife supervision on the island, and “assess whether there are sufficient mechanisms in place for protecting the safety of patients”.
“We are working closely with Guernsey’s Health and Social Services Department in order to protect the public,” she added.
The infant death rate in Guernsey is low in comparison to national figures for England and Wales. On average there has been one infant death each year in the 12 years to 2012, ranging from 0 to 3 in any given year.
The infant death rate for Guernsey and Alderney in the period 2010 to 2012 was one per 1,000 – significantly lower than the most recent comparison rate for England and Wales, which is 4.3 per 1,000.
Measures introduced since the incident
- There are now four midwives on every shift, one of whom will be a midwifery clinical lead. Previously there were three midwives on every shift.
- Therefore, there are now five midwifery clinical leads working on Loveridge Ward and another of these posts is currently being recruited to. These clinical leads will provide senior management, co-ordination and support. Their responsibilities will include risk management, clinical governance, training, development of services and practical clinical support.
- A Supervisor of Midwifery will be starting this month for six months. There is now in place 24/7 supervisory support from Jersey, and discussions are on-going regarding an on-island presence.
- The working patterns of obstetricians have been changed on a trial basis and will be subject to ongoing review.
- The way that medicines can be sought and agreed for administration during labour has been changed.
- Appropriate safeguards have been put in place but we cannot discuss individual employment matters