Damning maternity failings at Dudley's Russells Hall Hospital revealed
The safety of mothers and babies was put at risk at Dudley's Russells Hall Hospital, a damning report reveals.
The hospital was investigated following 43 ‘serious incidents’ over a 20-month period, including one death and five cases of ‘avoidable harm’.
A report released today has revealed a series of shocking failings within the maternity department, including:
- Monitoring of babies’ heart rates being ‘misinterpreted’ putting safety at risk
- Staff being slow to respond to urgent situations
- A lack of senior paediatric support to ‘assist with baby resuscitation at complex births’
- Russells Hall’s process for investigating serious incidents within its maternity unit was also said to be ‘inadequate’.
Documentation indicated clinicians were investigating cases but it was found this was not happening, resulting in ‘missed opportunities’ to prevent risk to babies in the future, the report said.
The concerns were flagged up by the Maternity Quality Improvement Board, which analysed 25 of the 43 serious incidents to see where lessons could be learned.
The incidents were recorded between April 2014 and December 2015 and caused alarm with NHS England as they were higher than any other West Midlands maternity unit.
Of the 25 that were investigated, 19 related to care affecting babies and the other six concerned mothers.
Councillor Peter Miller, cabinet member for health at Dudley Council, said the revelations were concerning.
He said: “Questions have to be asked and we have got to find the answers. That will have to be done.”
Diane Wake, chief executive of the Dudley Group NHS Foundation Trust, which runs the hospital, said: “We worked closely and openly with our commissioners and key health partners to form a quality improvement board in 2016 to review 25 maternity incidents that we reported between April 2014 and December 2015.
“Each of the 25 cases were thoroughly clinically reviewed and found that there were five cases of avoidable harm and sadly one baby died. We have been open with the families concerned and once again offer our sincere condolences and apologies.”
What the report says
Babies’ heart rates wrongly monitored, delays in concerns being raised with senior doctors and a failure to recognise mothers’ conditions deteriorating.
All were flagged up as part of failings within the maternity unit at Dudley’s Russells Hall Hospital in a damning report released today.
Hospital bosses were due to address the media today over the failings outlined in the report, which has been seen by the Express & Star.
The report raised a number of serious concerns about maternity care during the 20-month period. To make matters worse, lessons were not learned from the failings to prevent further harm coming to babies, the report states.
It says: “In January 2016, Dudley Clinical Commissioning Group (CRG) was informed by NHS England West Midlands (NSHE) that the Dudley Group NHS Foundation Trust had reported a higher number of serious incidents than for comparable maternity units in the West Midlands between April 2014 to December 2015.
“In addition to this, it was identified by NHSE that there was limited learning associated with these serious incidents.
“The CRG reviewed cases where the fetal heart monitoring was interpreted incorrectly and actions were delayed or not taken to avoid the potential of the baby being harmed.”
The report continued: “Despite there being a daily ward round where complex and/or high-risk cases were discussed, the review identified a lack of documentation reflecting appropriate consultant involvement in decision-making for women under obstetric management.
“External reviewers and members of the CRG identified a theme that staff, on occasion, were slow to respond to urgent situations and, in some cases, did not recognise deterioration in a woman’s condition in a timely way.”
Families affected by the serious incidents, including the mother of a baby boy who died, were written to last year, informing them of the probe.
The Dudley Group, which runs Russells Hall, said it had since introduced a ‘comprehensive improvement plan’ for maternity services, which ‘addresses the issues identified and provides assurance about the safety and effectiveness of the maternity services in Dudley’.