Another mum-to-be dies under care of Homerton Hospital
14:36 05 February 2015
Another mother-to-be has died at Homerton Hospital, becoming the fifth in a string of deaths which had already prompted an investigation.
NHS England (NHSE) was called in last summer to assist an internal review into how four mothers under the care of the maternity unit at the Homerton Row university hospital died within the space of eight months. In the whole of England and Wales in 2013 there were just 47 maternal deaths during pregnancy, childbirth and the six-week period following birth.
The hospital had already undergone one internal review, another from the Care Quality Commission and a further from the City and Hackney Commissioning Care Group following persistent allegations from an anonymous group of whistleblowers about “avoidable” deaths of mothers and babies there.
The deaths at the maternity unit occurred in July and October 2013, and January and April 2014, with the latter believed to have followed an elective caesarean section.
The latest expectant mother died on January 17, and a spokesman for Homerton said the matter was “in the hands of the coroner”, adding the case would not be included in its internal review, which is not yet complete.
The hospital has not revealed details of any of the cases, citing confidentiality and “potentially identifiable patient information”.
A group who dubbed themselves the “unhappy midwives” flagged up concerns two years ago about several unspecified serious incidents at the hospital, claiming women and babies were being exposed to poor standards of care and a culture of racial discrimination. Results of an independent investigation by the City and Hackney Clinical Commissioning Group (CCG) published in September concluded none of the allegations could be substantiated and did not identify any failings in the standard of care.
But the Gazette has since obtained an abridged copy of the report, which makes urgent recommendations.
The report recommends urgently addressing understaffing of consultants and supervisor midwives, and the extraordinary fact no obstetricians were available to undertake root cause analysis following any major incident.
It states that, although guidance was followed, incidents were not refered for further scrutiny “that may have been enabled the service to detect themes with incidents or individuals involved.
“In at least three cases that were reviewed the statements described missing equipment or inadequate rooms that could have an impact on the care provided.”
At the beginning of the CCG investigation in October 2013 the trust was advised to consider informing the Nursing and Midwifery Council (NMC). However the report points out that in early January 2014 – by which time three maternal deaths had occurred – it had not informed the NMC.
A spokesman for the trust said it was investigating the latest death which had been reported to the “appropriate authorities” – but could not say which ones.
A spokesman for the CCG said recommendations for improvement were being “closely monitored” by its Maternity Services Board. “Our overriding concern is, and always will be, to ensure women receive the best care possible,” he added.