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Lack of staff and poor organisation blamed for excess deaths in a London hospital

BMJ 2005; 331 doi: (Published 14 July 2005) Cite this as: BMJ 2005;331:128
  1. Susan Mayor
  1. London

    A shortage of midwives and obstetricians, poor working relationships, and failure to follow clinical guidelines was blamed for maternal deaths at a London hospital in a review published last week by the Healthcare Commission. The review was requested after seven women cared for by North West London Hospitals NHS Trust died in pregnancy or within 42 days of delivery, miscarriage, or termination of pregnancy between April 2002 and December 2003.

    The Healthcare Commission, which leads investigations into the provision of healthcare by the NHS in England, reviewed the quality of maternity care in detail. This included meeting staff and patients; visiting the trust's two main hospitals, Central Middlesex Hospital, and Northwick Park and St Mark's Hospital; analysing more than 750 documents; and surveying 400 women who had given birth at the trust in the six months leading up to the review.

    Nigel Ellis, head of investigations with the Healthcare Commission, said, “We found a number of serious problems, including a shortage of staff, poor working relationships between staff, poor communication, lack of information, and poor management. All of these contributed to what we considered was a significant failing in the service.”

    One of the most serious problems identified was a shortage of staff in maternity services, with a shortfall of 72 midwives identified in December 2004. The trust had been unable to provide one midwife per woman during labour. This had led to complaints from patients and low morale among maternity staff, who had to rely on agency staff or on existing staff working extra hours.

    The Healthcare Commission report called for urgent action to tackle the shortage of midwives. It also says that a workforce development plan must be agreed to meet current and future needs of the maternity service.

    Another reason for understaffing of maternity services was that consultants in obstetrics and gynaecology had been allowed to specialise in gynaecology, thereby reducing their involvement in obstetrics. This meant that consultants were not always available on labour wards.

    The commission's report recommended that a full time consultant obstetrician should provide clinical leadership on the labour ward, particularly for women assessed as being at high risk. Cover by consultants on the labour ward should be increased to 60 hours per week, as recommended by the Royal College of Obstetricians and Gynaecologists.

    Poor working relationships between different professional groups also caused problems. Clinical staff reported rigid professional boundaries and a lack of respect between different groups of staff. The commission recommended a programme of change to eliminate bullying and improve the staff's working relationships.

    The review found poor quality and poorly coded information. To improve this, it recommended the immediate introduction of a new information system for collecting, coding, and analysing information about the quality of care.

    At a national level, the commission recommended that the Department of Health, in collaboration with the Health and Social Care Information Centre and professional bodies, should develop and implement a national dataset for maternity services.

    Access to clinical guidelines in the trust was inconsistent, especially among midwifery staff, and compliance with local and national guidelines was not monitored, the review found.

    There were examples of clinical practice that did not comply with guidelines, such as symptoms of pre-eclampsia not always being identified and communicated to other health care staff at antenatal appointments and midwives not always monitoring a baby's heartbeat on admission of the mother. No evidence showed the provision of specialist services to tackle the needs of women who were identified as being at high risk.

    The commission recommended that up to date clinical guidelines should be widely available throughout maternity services and should be regularly reviewed. Awareness of and compliance with guidelines by the staff must be improved and monitored.

    Mr Ellis pointed out that special measures had been introduced during the review, in April 2005, when the trust appeared to be failing to make changes and a further maternal death occurred. This meant bringing in clinical staff from outside to provide daily supervision on the wards and external mentoring for the medical director designate and for the clinical director for maternity. “This meant that there was no delay in taking steps to improve the situation,” he suggested.

    The strategic health authority will now monitor the implementation of the action plan suggested by the commission, and the Department of Health will review progress of the local health community against special measures and action plans.

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