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HSIB's Summary Report on Maternity Safety Themes at East Kent Hospitals University NHS Foundation Trust
This week, the families of babies who died or suffered brain injury as a result of negligent maternity care at two maternity units run by East Kent Hospitals University NHS Foundation Trust begin sharing their experiences with the panel of investigators appointed to carry out an independent inquiry.
Investigations into maternity safety scandals of this size take time, but reports so far suggest that yet again, a lethal mix of poor leadership, unacceptably low standards and a toxic maternity team culture in which individual staff dared not raise concerns, have caused countless babies to suffer devastating harm. With warnings by audits, regulators and professional bodies ignored, and critical information withheld from the CQC, it was inevitable that mothers and babies’ lives were put at risk. With some parents only now feeling able to come forward, the true scale of the harm remains unclear, but unsafe maternity practises at the trust are believed to have caused the deaths of dozens of babies and left over 130 babies with permanent brain injury from birth asphyxia (lack of oxygen).
One of the organisations whose warnings were repeatedly brushed aside by the trust was HSIB. Their report, published in February 2020 in response to news of the scandal, shares details of their own role in the emerging awareness of East Kent’s maternity services failings and a summary of their findings. The report highlights themes which, although overwhelmingly prevalent in this extreme case, sadly threaten the safety of mothers and babies across NHS maternity care.
What happened at East Kent Hospitals University NHS Foundation Trust?
Earlier this year, The Independent reported concerns about the alarming number of babies who had died or suffered hypoxic brain injuries whilst under the care of East Kent Hospitals University NHS Foundation Trust’s maternity units at William Harvey Hospital in Ashford and the Queen Elizabeth the Queen Mother Hospital in Margate. Their reports revealed that the Royal College of Obstetricians and Gynaecologists (RCOG) had warned the trust’s management in 2016 that unless action was taken to improve its maternity services patient safety would be put at risk. Failings included consultants’ refusal to work during evening and weekend shifts, leaving less experienced doctors and midwives to manage complicated births, and allowing midwives to give women Syntocinon in labour without a doctor’s supervision. It was also reported that the RCOG’s critical report in 2016 was withheld from the CQC, which had rated the trust inadequate and placed it into ‘special measures’ in 2014, but then lifted the ‘special measures’ in 2017.
After the scandal was reported, NHS England set up an inquiry to investigate the babies’ injuries and make general recommendations for improved maternity care. The inquiry is now underway, with an expert panel led by Dr Bill Kirkup, a former obstetrician and gynaecologist and respected chairman of previous high-profile inquiries into NHS care scandals. Dr Kirkup was quoted as saying; “I will lead an investigation that is fair, thorough and independent.”
What is HSIB and what was their involvement at East Kent?
The Healthcare Safety Investigation Branch (HSIB) investigates patient safety concerns in NHS care in England. Since April 2018, HSIB has been responsible for all NHS maternity investigations for babies who meet the RCOG’s Each Baby Counts (EBC) criteria for stillbirth, brain injury and neonatal death.
Between July 2018 and January 2020 HSIB investigated 24 maternity safety incidents from East Kent. These included 19 babies who had received cooling for hypoxic brain injury, three neonatal deaths and two maternal deaths. In December 2018, HSIB first raised its concerns about recurrent maternity safety themes with trust management and asked them to consider, respond and escalate the concerns to their own trust board and up through regional and national reporting channels. HSIB repeatedly advised the trust of their concerns until August 2019 when, after no evidence of any improvement, HSIB asked the trust to report itself to the clinical commissioning group (CCG) and the CQC. HSIB also escalated the matter itself to the CQC, to ensure that they were aware of their safety concerns.
What does HSIB’s report say about East Kent’s failings in maternity care?
HSIB found repeated risks to patient safety from its East Kent investigations, in four key areas of maternity care:
1. CTG interpretation
HSIB raised concerns about fetal heart (CTG) monitoring, including the unavailability of staff with suitable skills in interpreting CTG results and inconsistency in the way results were classified to recognise or escalate results which were a cause for concern. Specific examples of HSIB’s recommendations included:
- ensuring that CTG interpretation is in line with NICE guidance;
- ensuring staff follow fetal blood sampling guidelines in labour, especially if there are concerns with the CTG;
- that staff who interpret and categorise CTG results understand assessment of the fetal heart, its classification and escalation;
- updating local guidelines on assessment and interpretation of CTGs to reflect current guidance and practice;
- ensuring the fetal heart rate is identified separately from the mother’s heart rate using a Pinard’s stethoscope before CTG monitoring starts, and checking with ultrasound scanning if they appear to be the same ;
- the on-call manager should attend when acuity levels (intensity of care needs) are high to provide the correct level of care and escalation;
- if a CTG is pathological (abnormal), preparations should be made to start immediate resuscitation of the baby at birth, including escalation to the paediatric team.
2. Neonatal resuscitation
Lack of effective or timely neonatal resuscitation was a major concern. Resuscitation equipment was located too far away from the ward, causing added delay, risk and distress in emergency situations. There was a lack of skilled support for the staff who were responsible for resuscitation. Essential timings and APGAR score assessments were not recorded properly during resuscitation as nobody was allocated that responsibility. There was a lack of clear processes and communication to call for neonatal help when a compromised baby was about to be born which added to the problems with resuscitation. HSIB’s recommendations in this area included providing resuscitation equipment in or next to the delivery room.
3. Recognition of deterioration
HSIB found that maternity staff didn’t always recognise the signs and symptoms indicating that a mother or baby’s condition was deteriorating, which meant that opportunities to prevent further deterioration were missed. Specific recommendations included:
- all staff should maintain a high level of suspicion about vaginal bleeding at term, and comply with guidance;
- a full review of processes and procedures for when a baby is born needing resuscitation, including issues with delays, transfers, separating babies from their parents, risk assessment and communication with members of the multi-disciplinary team;
- emergency procedures for neonatal resuscitation should be reviewed;
- the trust should carry out a full risk assessment for when babies are taken out of delivery room for emergency treatment and ensure that all birthing rooms have equipment for neonatal emergencies and resuscitation;
- ensuring that neonatal resuscitation is correctly documented;
- ensuring that an identified clinician has ownership of each case, to question, review and monitor when a mother is not responding to treatment and ask the necessary questions to ensure timely coordinated care.
4. Escalation of concerns and responses
HSIB found that escalation procedures were inconsistent. Factors affecting escalation included site-based or professional team alliances, and skill gaps within specialisms and wider teams. Midwifery staff were reluctant to escalate their concerns to obstetric and neonatal colleagues. HSIB’s recommendations included a review of obstetric and maternity escalation processes so that frontline staff can call for help, and maternity staff in the midwife led unit can call for help from the labour ward coordinator in the delivery suite in an emergency.
Boyes Turner’s birth injury team can help brain injured babies obtain full compensation
As HSIB point out in their report, sadly these type of maternity safety concerns are not new. We welcome the news that this inquiry is underway, ably led by Dr Kirkup and his experienced team, who will no doubt share our despair that so little has been learned from the harm suffered by those whose care was investigated under his leadership of similar inquiries.
Meanwhile, Boyes Turner’s experienced cerebral palsy and birth injury lawyers understand the devastating impact that each and every one of these avoidable personal tragedies have on the severely injured babies and their families. For many, their severe disability will affect every aspect of their lives. Their families have the right to know the true cause of their child’s catastrophic injury and we remain committed to ensuring that these children receive their full entitlement to compensation.
If you are caring for a child with cerebral palsy or neurological disability caused by errors in maternity or neonatal care and would like to find out more about making a claim, contact us by email at firstname.lastname@example.org.
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