What is the review?

Following the recent inquiries into maternity services at East Kent Hospitals University NHS Foundation Trust, Nottingham University Hospitals NHS Trust and Shrewsbury and Telford Hospital NHS Trust, University Hospitals of Derby and Burton NHS Foundation (the Trust) requested an independent review of seven maternity incidents that took place at the Trust between January 2021 and May 2022.

The cases sadly related to three maternal deaths and four maternal collapse / cardiac arrests.

The Trust stated that it recognises that other reports have ‘highlighted the need for openness to learning from incidents.’ It is reassuring to see that the Trust is being transparent with the public and families and is open to learning from incidents.

The review was undertaken by the Healthcare Safety Investigation Branch (HSIB), which is an independent national investigator of incidents that have harmed NHS patients.  

The findings

The review found that there were no common themes that contributed or impacted on the outcomes of the incidents. 

It identified the following:

Positive outcomes

• Staff were passionate about delivering a high-quality service for patients. 
• There was a kind and compassionate culture amongst staff.
• Two new consultant positions had been filled.
• A recent change meant that two experienced speciality doctors were working together on an elective caesarean section list.
• Both the emergency and elective theatre environments were calm, spacious, and modern.
• In recent months there has been a new approach to governance.

Negative outcomes

• Since the Trust merged in 2018 there has been a fragmented leadership particularly in midwifery.
• The Trust has significant midwifery staffing gaps which impacts on women’s experiences.
• Staffing levels remain a challenge.
• There are vacancies at consultant level which effects the operating lists, but a recent change to have two experienced speciality doctors working together on an elective caesarean list is welcomed.
• There are significant opportunities for the Trust to optimise process elements of the management of massive obstetric haemorrhage.
• Documentation was not fully complete.
• There were examples of a lack of willingness to involve women and their families in their care and a lack of follow up once women were discharged.
• Until summer 2022, the maternity safety review process was a ‘closed process, inconsistent and held erratically.’

The Trust has listed on its website several changes that have already been made including revising the major obstetric haemorrhage guidance, enhancing the existing incident process, appointing two new consultants and offering roles to 18 new midwives from overseas.

The Trust’s own comments on the review can be found here – UHDB Review

The full review can be found here – HSIB Review

What will be the outcome of the review?

It is hoped that the Trust will implement changes based on the findings and recommendations from the HSIB review and that the maternity services, not only at Derby but across the whole NHS, will continue to improve.

We have seen the devastating impact that failures in maternity services have caused at East Kent, Nottingham and Shrewsbury & Telford hospitals and it is encouraging to see Trusts such as Derby ensuring that they learn from incidents before they escalate and putting in place improvement measures.

At Moosa-Duke Solicitors, we hope that this review, and other maternity inquiries, will initiate change and improvements to maternity services across the NHS.

If you have concerns about the maternity care that you or a family has received, please contact our specialist team for a no-obligation consultation on 0116 254 7456 or at enquiries@moosaduke.com.