A damning report on maternity services in Guernsey has raised serious concerns over the quality of care and supervision of pregnant women.
The NHS England South West Guernsey Extraordinary Review found that standards relating to how midwives’ practice was being supervised at the Princess Elizabeth Hospital on the island had not been met.
Public protection issues needing urgent attention included the judgments made by three Supervisors of Midwives (SoMs) who had since been made to take enforced leave of absence.
“[The two reports] raise widespread issues which could undermine public confidence in the safety of maternity services on the Island
The extraordinary review looked into their competence and capability, a significant under-spend in the training and education budget for midwives, and evidence of poor practice in relation to the security and safe storage of maternity records, according to two reports published by the Nursing and Midwifery Council.
The hospital, which has a 12-bed antenatal and postnatal ward, four delivery rooms, a two-bed transitional care unit and a three-bed neonatal unit, is currently receiving interim support from SoMs based at the Jersey General Hospital, the review said.
But the Jersey SoMs had expressed concerns that although they were providing “adequate, effective and timely support to midwives and women in Guernsey” they were worried about “the sustainability of providing midwifery supervision in Guernsey in the long term and the potential negative impact” it may have on their own hospital.
The incident which had led to the three SoMs being suspended related to a neonatal death where poor midwifery practice had been reported internally but not thoroughly investigated, the review said.
The reports also found that midwives’ diaries containing personal details of women were easily accessible on a shelf in an office.
Diaries from 2008 to 2012 were located in a box next to the senior midwife’s office, an area which was neither safe nor confidential, indicating a lack of awareness of personal responsibilities of midwives to store data safely, according to the review.
The content of the diaries also demonstrated that midwives had used them to record information regarding women who they were to care for, during the handover of shifts, it said.
Two birth registers were found on shelves which were openly accessible within the office and maternity records were in filing trays which were not securely stored and were accessible to others, the report added.
The review team also spoke to pregnant women and practising midwives, who raised concerns over the care environment, policies and procedures, governance, leadership and management, and organisational culture.
“The safety of our patients is of paramount importance, and the NMC report shows that our midwifery and wider maternity services do not currently serve our patients well enough in that respect”
Women reported that they were afraid to complain about poor maternity care for fear that they would be dealing with the same midwife in a subsequent pregnancy, and one woman said she would consider staying at home in her next labour rather than going into the Princess Elizabeth Hospital to ensure she received the birth she wanted, the review said.
Midwives reported delays of 60 to 80 minutes for women needing emergency Caesarean sections because medical and theatre staff would have to be called in from home.
The report said: “The midwives stated that they were very anxious for the woman and baby during these situations, particularly as they had to await the arrival of consultants from home.
“This was a concern as many women were considered as high risk and the midwives reported ‘looking at the women thinking is this baby going to be alive or dead?’.”
The reviewers also found no baby tagging system in operation and that maternity staff relied on the ward entry doors to avoid any potential baby abduction.
The report said: “We observed one room that had a door that was unalarmed and could have easily assisted someone who wanted to abduct a baby from the ward area.
“The senior manager was informed who alluded to ‘this is Guernsey, it’s laid back … we don’t lock things’.”
The NMC, which sets standards for midwifery practice and the supervision of midwives, said it had been informed that the Local Supervising Authority and Guernsey’s Health and Social Services Department had put measures in place since the review visit at the beginning of October in order to address some of the immediate concerns raised in the reports.
Jackie Smith, NMC chief executive and registrar, said: “When taken together, the two reports we have published raise widespread issues which could undermine public confidence in the safety of maternity services on the Island.
“These reports were commissioned in the interests of public protection and in order to drive urgent improvements in maternity care in Guernsey.
“We are working with the Local Supervising Authority and Guernsey’s Health and Social Services Department to make improvements in order to protect patients and the public.”
Paul Luxon, who took over the role of Guernsey’s minister for health and social Services yesterday, said: “My first priority, and that of my new board, is delivering a positive, robust, sustainable and long-term response to the NMC’s extraordinary review.
“The safety of our patients is of paramount importance, and the NMC report shows that our midwifery and wider maternity services do not currently serve our patients well enough in that respect,” he said.