Basildon University Hospital Maternity Unit – Urgent Improvement Required
Basildon University Hospital in Essex has been ordered to carry out urgent improvements following a whistleblowing incident which raised fears about patient safety. The hospital is run by Mid and South Essex NHS Foundation Trust.
The Care and Quality Commission (CQC) have rated the unit as inadequate in a recent report. Sadly, failings have been found in six serious incidents. These incidents related to babies that were born in a poor condition and required cooling therapy in March and April 2020. Cooling therapy is a treatment for newborn babies with brain injuries caused by oxygen shortages during birth.
The CQC noted lessons had not been learned from a previous inspection following the death of a mother in 2019, Gabriela Pintilie, who sadly died hours after giving birth by C-section.
CQC Report Findings
Inspectors have found the following problems that led them to conclude that the maternity service was inadequate:
- Staff did not always complete training in key skills and did not identify and escalate safety concerns appropriately
- The service did not always have enough maternity staff with the right qualifications, training, skills and experience to keep women safe from avoidable harm and to provide the right care and treatment
- Attendance at staff training was inadequate
- Dysfunctional working between midwives, doctors and consultants, which had an impact on the increased number of safety incidents reported
- A lack of response by consultants to emergencies resulting in delays
- High-risk women inappropriately giving birth in a low-risk area
- Senior medical staff did not support, supervise and mentor junior medical staff effectively and some staff did not feel able to approach some colleagues, which was not to the benefit of women and babies
- A lack of open culture for staff to raise concerns without fear
- Concerns over foetal heart monitoring
- Delivery suite birthing rooms were not in line with national guidance
- Women being referred to by room numbers instead of their names
It was noted that the five serious incidents following Gabriela Pintilie’s death had the same failings of care involved, demonstrating a lack of learning from previous incidents and actions put in place were not implemented.
A warning notice has been issued by the CQC that requires the Trust to make urgent improvements to ensure mothers and babies are safe.
What more should be done?
It is clear that there are deep issues in maternity care throughout the NHS. Just recently we have seen the East Kent Hospitals Maternity scandal and the criminal inquiry launched into the Shrewsbury and Telford Hospital NHS Trust Maternity scandal. It is devastating and frustrating to see the same mistakes being repeated throughout various NHS Trusts.
It has recently been announced that the safety of maternity services in the NHS are to be investigated by the Health and Social Care Select Committee with a focus on why these incidents keep re-occurring and what needs to be done to improve safety. I am pleased to see that a national review is finally taking place and I hope that valuable lessons are learned and implemented to ensure that we see the end of these tragic scandals.
None of these mothers and babies should have suffered in the way that they did and it is a disgrace that lessons were not learned following the tragic death of Gabriela Pintilie. It is not acceptable that the same mistakes are made again and again.
We must not forget the real life tragedies at the heart of these headlines. These failures can lead to devastating, life changing injuries or the avoidable deaths of mothers and babies, having a huge impact on the families involved. The families involved in the serious incidents noted in the report deserve answers and urgent changes to hospital culture are needed. Levels of safety in maternity services must be improved at an NHS wide level to ensure that no other family has to go through these tragic and avoidable experiences. Women need to know that they and their babies will be safe.