The Healthcare Commission has recently published an investigation
report into the deaths of ten women who gave birth
at Northwick Park
Hospital, West London.
The findings have prompted the inspectorate to renew its call for
NHS trusts to check that they have robust systems for monitoring
the safety of maternity units.
The report describes what happened to each of the ten women, all
of whom died during pregnancy or within 42 days of giving birth between
April 2002 and April 2005. This number of deaths was significantly
higher than the national average for maternity.
In April last year, the Commission stepped in and recommended that
the Government place North West London Hospitals NHS Trust under
special measures, calling in an external team to safeguard women
at Northwick Park Hospital's maternity unit.
This report, which aimed to identify if there were common factors
between the deaths, paints a stark picture of what can happen when
a maternity unit has inadequate systems to protect the women it cares
The Commission criticises the quality of care given by the Trust
in nine out of the ten cases.
Common factors include:
- insufficient input from a consultant or a senior midwife (in
five cases), with difficult decisions often left to junior staff.
- failure in a number of cases to recognise and respond quickly
where a woman's condition changed unexpectedly
- inadequate resources to deal with high-risk cases: too few consultant
obstetricians and midwives; not enough dedicated theatre staff;
a reliance on agency and locum staff without adequate managerial
professional support; and a lack of a dedicated high dependency
- a working culture that led to poor working practices
and resulted in poor quality of care
- failure to learn lessons on the unit - the Trust took action
following the deaths but the working environment was such that
- failure by the Trust's board to appreciate the seriousness
of the situation – the board was aware of the high number
of deaths, and should have acted sooner to rectify problems.
The Commission does not criticise all aspects of the hospital's
care. Anaesthetic staff and the haematology department, which provided
blood for the patients, were praised for responding well under difficult
The Trust remains under special measures, but the Commission says
there have been significant improvements in the maternity services
provided there. These have included the recruitment of three additional
consultants and 20 more midwives.
The inspectorate also believes there is now better team working
between consultants and the obstetric staff, and between the obstetric
staff and midwives.
Marcia Fry, the Commission's Head of Operational Development,
“ This was a sad and tragic series of events. We hope
this report at least gives some answers to the families involved.
_ At the time of the deaths, the
working practices at the Trust were unacceptable. However, under
special measures the Trust has
got its maternity services on the road to recovery. We will continue
to work with them to ensure that they continue to progress and that
everything possible is done to stop this happening again."
Mrs. Fry added:
“We expect trusts across the country to read
this report and learn the lessons. Most women in this country give
birth safely. But there are risks and the NHS must ensure it does
all it can to reduce them. There can be no excuse for failing to
learn the lessons from tragedies of this kind.”
This is the Commission's second report into Northwick Park
Hospital's maternity services. The first, in July 2005, identified
system failures including lack of leadership and weak risk management.
This report outlines the impact on the ten women concerned.
Last year, Commission Chairman Sir Ian Kennedy called on NHS trusts
to raise standards in their maternity services to those of the best.
He drew on the similarities between Northwick Park and two other
trusts where maternity services had been investigated.
Sir Ian said the overall root cause of poor performance is often
weak managerial or clinical leadership which can leave problems unidentified
or unresolved. He also highlighted:
- weak risk management with poor incident reporting and complaints
- poor working relationships and working in multi-disciplinary
- inadequate training and supervision of clinical staff
- poor environment with services isolated geographically or clinically
- shortages of staff coupled with poor management of temporary
The Commission is stepping up its assessments of maternity services,
which will provide it with information on patient experience
and clinical outcomes. It is planning a major survey of looking at
experience of maternity care, as well as a national review of
maternity units, which will include clinical indicators that
enable NHS trusts
to compare their performance.