Maternity investigation finds deaths at Royal Derby Hospital could have been prevented
Three mums and a baby died, whilst four other mums suffered 'extreme consequences'.
Last updated 22nd Feb 2023
WARNING: Some of the detail in this article you may find distressing.
Three mothers and a baby died and four further mothers suffered 'extreme consequences' during and following childbirth at Royal Derby Hospital, a new report has disclosed.
A new independent report from the Healthcare Safety Investigation Branch, publicly released by the University Hospitals of Derby and Burton NHS Foundation Trust, covers seven cases involving pregnant mothers and their babies.
Glaring issues with communication, staff shortages, a bullying culture between teams caring for mothers and babies, and delays to care are among the issues within the cases of the seven mothers – leaving the surviving parents and families traumatised and frustrated.
The incidents involving the seven mothers and their babies took place over the course of 16 months from January 2021 to May 2022, and involved mothers aged 28 to 42, with six cases wholly taking place at Royal Derby – three in gynaecology theatre and three in labour ward theatre – and one starting at the patient’s home.
The review found:
A mother and her baby both died after the mother had a heart attack at home, with delays in Royal Derby staff calling for emergency support
A mother who died following the birth of her child had waited 57 minutes for an essential blood transfusion.
A mother cannot remember the birth of her child after complications during the procedure, she is in disbelief that the trust discharged her home without telling her “anything” about the issues she faced
A mother did not hear from the trust for four months after she was discharged from intensive care, suffering complications during childbirth
A mother says the trust’s support has been “awful”, with no memory of her incident after having a heart attack following childbirth, with the unexplained incident leaving her too scared to walk down her road
While the investigation, which was actively requested by the trust, reports that it did not find any common themes that affected the “outcomes” of all seven cases, it did state two “crucial areas of safety improvement that require prompt action” to help protect further mothers and their babies.
It concludes: “It is not possible to know if a different approach to safety investigation and implementation of learning, or a different safety culture within the maternity unit could have influenced a different pathway of care prior to the critical events.”
Dr James Crampton, the hospital trust’s executive medical director, said:
“The seven incidents have had a longstanding impact on the families involved, so it was paramount to us to ensure we had utilised every possible opportunity for further learning and why we proactively requested this independent review.
“Although the review did not find any common themes that impacted on the outcomes for all the women involved, there has been learning for us an organisation which we have taken very seriously, and the recommendations are invaluable in helping us to further improve safety and the experience of women under our care.
“We have already addressed the report’s immediate recommendations, including refining our existing major haemorrhage guidance and enhancing our emergency bleep process, and have put a comprehensive plan in place to rapidly deliver all other initial actions within the next three months.
“We would like to reiterate our apologies to the seven women and families for the experiences they had and we thank them for their strength in sharing their feedback, which we will commit to using to improve the experience and care we provide to others.”
The trust says it is revising its major obstetric haemorrhage guidance, is looking to increase bereavement support roles and hire a family liaison officer, and had ordered a blood fridge.
Outside of the review it says it has offered roles to 18 overseas midwives, and two new consultants will start in February and March, along with “retention midwives” aimed at supporting the development staff at the trust.
Last year, 5,850 babies were born at Royal Derby Hospital.