HSIB Review of Maternity Services
HSIB Review of Maternity Services at the University Hospitals of Derby and Burton NHS Foundation Trust: Published on 22 February 2023
The Healthcare Safety Investigation Branch (HSIB) has undertaken a review of maternity services at the University Hospitals of Derby and Burton NHS Foundation Trust following a number of maternal deaths and maternal collapse events between January 2021 and May 2022.
The report looked at the circumstances surrounding three maternal deaths and four maternal collapses during this period. The report found that there was no common theme to the incidents that occurred but it did identify a number of concerns and safety recommendations.
Trust Merger
There were inconsistent policies, processes, guidelines and leadership following the Trust merger in 2018.
Staffing
There were staffing concerns caused by short- and long-term sickness absences as well as difficulties in retaining and recruiting staff. The reduced staffing levels weren’t thought to have contributed to the outcome of any of the seven incidents investigated but there were concerns that this could impact the experience of other patients.
Bullying
There was evidence of bullying and a hierarchical culture amongst the senior and leadership teams. Again, this was not thought to have directly impacted the care given to the seven women involved in the report but the HSIB deemed this an important point to highlight and address.
Safety
Safety improvements were needed to optimise the management of major obstetric haemorrhage.
Communication and Follow Up
There was a lack of follow up once the women and / or their families had left hospital. This led to them feeling abandoned by the Trust and unable to share their experiences. Following the review the HSIB made five safety recommendations and ten safety prompts which the Trust have accepted. A statement from the Trust’s executive medical director, Dr James Crampton indicates that steps have already been taken to improve guidelines. The Trust has also apologised to the seven women / families affected. The findings of the report are deeply concerning and it is devastating to read about the experiences of these seven families at what should have been one of the happiest periods of their lives.
If you have been impacted by the substandard care provided by the University Hospitals of Derby and Burton NHS Foundation Trust or elsewhere then our specialist team of clinical negligence lawyers may be able to assist and support you with a claim for compensation.
Author: Roisin Hulme, Solicitor, Medical Negligence
