The cases which occurred over a period of 16 months happened at the University Hospitals of Derby and Burton (UHDB) NHS Foundation Trust. The investigation carried out by health watchdog- the Healthcare Safety Investigation Branch (HSIB) also discovered that bullying and intimidation was a norm and issued some recommendations as regards patient and staff safety.
The trust described the recommendations as invaluable and issued an apology to the affected families.
The report noted that the causes of the death and four other life-threatening cases that happened were not exactly the same. However, it noted inconsistencies in process and leadership.
The HSIB said “robust action planning and prompt addressing of the learning” from previous recommendations from other investigations “may have had an impact on the outcome for the women who received care during the seven events included in this thematic review”.
Other significant issues noted by the trust included understaffing with the maternity service. As at the time of the report, 45 midwife vacancies had been written.
The review team found strong evidence of poor behaviours, intimidation and a culture of hierarchy mostly within the obstetric team.
According to the report, six of the cases explored in the thematic review occurred at the Royal Derby Hospital, while the other case involved a woman who died at home.
Aaron Horsey, from Nottinghamshire, whose wife Bernadette died at the trust, said she had been booked for an elective Caesarean section on 19 January 2022. According to him, one of the reasons his wife decided to have their baby Derby was the concerns over maternity care services in Nottingham even though Bernadette worked for Nottingham University Hospitals Trust.
This is what he said; “The procedure seemed to go quite normally and we were told there was a bit of an increase in activity and Bernadette said she felt very strange.” He added that after their baby arrived, the surgeons allowed him and his wife a moment to look at him. That moment Aarons said felt like forever, seeing him arrive.
Aaron continued, “I turned to Bernadette to say ‘he’s here’ but she immediately slumped to one side. She was white-grey and had a very unusual breathing pattern which I recognised from doing some first aid training. She wasn’t conscious any more. I was shouting at her, I was holding her arm and I gave her a really good squeeze”.
Despite insisting on staying in the room, Aaron was taken out of the room to a room outside where one of the consultants told him Bernadette was in cardiac arrest. He was later informed of her death.
Responding to the published report, Mr Horsey said: “My first thoughts are with the other affected patients and their families. Whatever this review said, nothing could fix the situations we each found ourselves in. It is clear that Derby Hospital failed to learn from previous investigations and that impacted the patients included in this review. They must do better for future patients.”
Bernadette’s family continue to wait for an inquest into her death.
Reacting, the trust said it had directed an independent review by the NHS Derby and Derbyshire Integrated Care Board into seven maternity incidents that occurred between January 2021 and May 2022.
Dr James Crampton, UHDB executive medical director, said “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”.
He concluded by issuing an apology to the seven women and families for the experiences they had and thanked them for their strength in sharing their feedback.
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