“NHS failings caused avoidable deaths” – An internal report showed many mothers and babies tragically died due to ‘clinical errors, poor staff attitudes and chronic shortages’

According to a recent NHS report, numerous mothers and babies tragically died at NHS hospitals in Manchester and Oldham.

The medical review was carried out in June by the maternity director, Deborah Carter, at the Pennine Acute Hospital Trusts, which operates North Manchester General and Royal Oldham hospitals. The report highlighted that mothers and babies were dying due to ‘clinical errors, poor staff attitudes and chronic shortages’. Ms Carter highlighted that negligence caused a ‘string of avoidable deaths and long-term injuries caused by failures over many years’.

The bad attitudes of employees were detailed in the report. In one instance, a very premature baby was left in a Moses basket to die alone in a sluice room, which is completely heartbreaking to read about. This was a room where bedpans are washed and emptied, sick bowls are kept, solid waste is disposed of etc, and it’s a cleaning room as well as where medical waste is stored in the hospital.

It’s no place to put a premature baby; the actions of the staff in this instance are completely unacceptable.

The baby was born 22 weeks and 6 days into the pregnancy, but didn’t survive more than two hours. As the baby was born before the legal age of viability (23 weeks), staff couldn’t resuscitate her. Nonetheless, the staff failed to find a “quiet place” for the grieving mother to nurse the baby before the death.

Poor staff attitudes also led to a mother dying from a “catastrophic haemorrhage” after her symptoms were ignored and misdiagnosed as a mental illness. Staff ignored the mother’s symptoms of hypoxia, which is caused by a lack of oxygen reaching the tissues.

The report also detailed that long-term failures had caused “significant harm to women”, and poor standards on maternity wards resulted in “high levels of harm for babies in particular”. Shortages of staff meant that a baby died because antenatal staff failed to identify the mother’s rare blood type. Bed shortages in Oldham Hospital meant that high-risk pregnancies were transferred to North Manchester General.

This all put women and infants at an “unacceptable risk”.

A shortage of NHS staff meant that the Trust relied heavily on locum staff, which made up a third of the team. As such, this led to a make-shift team which “lacked specific skills and competencies” and led to women receiving fragmented care, long waits, and mismanagement.

The review only came to light after a FOI request

The review only came about following a Freedom of Information requested by the Manchester Evening News. The newspaper claimed that Pennine Acute Hospital Trusts tried to suppress the report, and even more shockingly, tried to claim that the internal report didn’t exist.

Not the first time…

This isn’t the first time the NHS Trust has come under fire for the diabolical treatment. Back in 2003, a premature baby was found crying in a sluice room after the doctors announced a stillbirth. At birth, David Green, weighing just under 2lb, suffered irreversible damage. The doctor was unable to hear a normal foetal heart rate, and believed the child had died. The NHS staff allegedly failed to take an ultrasound scan, which would’ve confirmed that the baby was still alive.

An action plan for the Pennine Acute Hospital Trusts

The NHS report sets out actions that are required from the NHS Trust which include:

  • Strengthening of leadership within the maternity wards.
  • Review and establish the team substantively so that the reliance on locums is removed, replacing them with staff with more specific and focused skills.
  • Support from experienced midwives particular at North Manchester General Hospital.

The Trust received more legal claims than any other Trust in the period of 2010 – 2015. Within that time, £25 million worth of damages were paid out, with nearly half of the claims relating to mothers and babies.

This highlights the ongoing issues within the NHS Trust, they must rectify these issues urgently before any further unavoidable deaths are caused.

Sources:

http://www.telegraph.co.uk/news/uknews/1436737/Baby-found-in-sluice-room-sues.html

http://www.independent.co.uk/life-style/health-and-families/health-news/premature-baby-died-pennine-acute-hosptials-nhs-trust-manchester-sluice-room-north-general-royal-a7435936.html

https://www.scribd.com/document/332071296/Internal-review-into-maternity-services-at-Pennine-Acute-NHS-Trust-hospitals

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