Maternity Deaths were Avoidable - Hospital Inquiry


Of the deaths of 42 women in London over 18 months, 17 could have been prevented by proper maternity care, according to a report seen by BBC Panorama.

After the total number of maternal deaths in 2008 were exceeded in just the first half of 2009, the NHS asked an independent body to investigate.

Its report found that some of the hospitals' own inquiries into the deaths were not always accurate or objective. Of 29 serious incident reports scrutinised for the review, the expert panel agreed with only 12, stating that many hospital-based inquiries were "defensive in nature".

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The panel disagreed with six inquiries that concluded the deaths were unavoidable, saying "different management and earlier diagnosis could have changed the outcomes".

The report also discovered that many mothers did not contact maternity services until late in their pregnancies. Of the 42 who died, half were from deprived backgrounds and two-thirds were from ethnic minorities.

NHS London's chief nurse said it has addressed shortcomings in maternity services across the organisation. Prof Trish Morris-Thompson, who is also a practising midwife, said: "There were a number of opportunities to prevent death occurring and because of that, we have taken enough action across the organisations in London and we will continue to do so to put right those actions."

"While less than optimum care was given and death did occur, however, in the context of 200,000 births during that period a lot of women were cared for."

Using Freedom of Information requests to survey maternity services across the UK, Panorama contacted all 171 UK maternity units and received replies from 88%. It found that maternity units temporarily closed their doors to new admissions 1055 times in 2010, resulting in at least 927 women needing transfer to other maternity units, a 32% increase over the previous year.

Almost half the closure cases were caused by staffing issues, with units being at capacity the second most cited reason. The staff shortages came as the UK experienced the highest number of births in almost 20 years.

Asking the vacancy rate for midwives at each unit, the survey learned that in Wales and Northern Ireland it is below 1% and in Scotland just above 1%. Whilst the rate in England is nearly 5%, in some London NHS trusts the rate is as high as 20%.

According to the Royal College of Midwives (RCM), providing a safe service depends on hiring at least another 4,700 midwives across England and Wales.

The college's Cathy Warwick said: "The problem for midwives now is that the pressure is relentless and none of us can keep our standards as high as they should be if day after day we're working under extreme pressure."

Health Minister Paul Burstow said in a statement: "Safety is paramount in the NHS and all mothers and their babies should expect and receive consistently excellent maternity care."

"We will continue to work with the Royal College of Midwives to make sure we have an appropriately resourced and skilled maternity workforce based on the most up-to-date evidence."

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