Newborn death - NHS maternity unit was ‘short of midwives’
Maternity services at Milton Keynes general hospital where newborn baby Ebony McCall died and mothers in labour were left unattended due to a shortage of midwives were "nothing short of scandalous".
Standards of care at the hospital had not improved despite warnings from the health watchdog last year according to the deputy coroner for Milton Keynes, Thomas Osborne.
The hospital had been subject to a Healthcare Commission investigation after Osborne oversaw an earlier inquest into the death of another baby, Romy Feast, who was born in 2007 by caesarean section but died after monitor readings were misinterpreted.
That investigation found that a shortage of beds and midwives meant mothers were being discharged prematurely. The unit also had a re-admission rate nearly three times the national average.
The inquest heard that Ebony McCall was born by caesarean section in May this year after her mother was admitted to hospital with stomach pains. She was initially refused a caesarean section, but went into labour that night after the baby's heartbeat became erratic, necessitating the emergency procedure she had wanted in the first place. McCall told the inquest she had agreed to a planned induction after meeting a consultant, Anthony Stock.
Ebony died shortly after her birth, early on 9 May. Recording a narrative verdict, and questioning the hospital's failure to act on the Healthcare Commission's findings, Osborne said: "Anyone who has listened to the evidence cannot help but be appalled by the pressures that are placed on midwives. The situation where mothers are left unattended during labour and other mothers are unable to get an epidural is nothing short of scandalous. If this situation is allowed to continue the lives of babies and mothers who intend to have their babies at Milton Keynes hospital will continue to be at risk."
The Care Quality Commission (CQC), which has taken over from the Healthcare Commission, condemned the hospital for failing to strengthen its maternity care.
Amanda Sherlock, the CQC's deputy director of frontline operations, said: "It is clear that the unit was insufficiently prepared to cope with the pressures on that particular night. There have been improvements since last year's assessment, but more needs to be done. It must plan for high levels of demand and ensure it has systems in place to cope."
Adrian Desmond a leading medical negligence lawyer from Reading based Boyes Turner said: “So many instances of negligent care during birth result not from individual errors of medical and midwifery staff but from systemic error resulting from the failure of hospital managers to ensure that delivery suites are adequately staffed. This would appear to be exactly the situation in this case - all the more deplorable because of problems previously encountered at that hospital which suggests that the hospital is not learning from its mistakes.”
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