Midwives at Margate’s QEQM Hospital had to make decisions on the care and treatment of high risk women that should have been made by a doctor, says the Care Quality Commission.
The health watchdog has raised the concern, amongst others, in a letter to the East Kent Hospitals University Foundation Trust following an inspection of maternity services last month.
The letter to trust chief executive Susan Acott also highlights concerns over junior nursing staff are being rostered, with responsibility for day care, without sufficient senior support at William Harvey Hospital and says “the risk assessing of women is not robust and correct pathways are not identified to be able to provide the necessary care and treatment.”
The unannounced inspection was carried out between January 22 and February 5. following a number of preventable baby deaths at QEQM and William Harvey hospitals, including that of one week old Harry Richford.,
A BBC investigation cites the deaths of Harry Richford; four day old Archie Powell, born on February 10, 2019 who died after a failure to spot group B streptococcus; Tallulah-Rai Edwards who was stillborn on January 28, 2019, after monitoring failures; Hallie-Rae Leek who died on April 7, 2017, aged four days, after struggles to find a heartbeat and delays in her delivery; Archie Batten, who died on September 1, 2019, shortly after birth when his mother, in labour, was told the QEQM maternity unit was closed and she should drive herself to the William Harvey in Ashford and two stillbirths in 2016 due to monitoring errors.
An independent review by NHS England is now being carried out into the maternity services care Trust sites and an.independent clinical support team has also been parachuted in to oversee the care being delivered.
In the CQC letter other concerns are that observations are recorded but early warning scores are not calculated to assess whether care and treatment should be escalated; staff are not routinely reporting incidents when the issues impact on care; and the trust’s auditing of the service provision has not been effective in identifying these concerns.
Inspectors say they found risks within triage and day care at the QEQM. The letter adds: “It is a risk known to the trust, that midwives may not be escalating in a timely way, to medical staff, when fetal distress has been identified, to make sure that medical staff are present as necessary for when that woman gives birth.”
Improvements were also noted including the employment of several specialist midwife posts and the trust ensuring there is a point of contact for families after the death of their baby.
In response to the letter Mrs Acott (pictured) said a red/green/amber system had been introduced for women using the triage system, gaps in the rosters were being dealt with to make sure there was always a band six or seven midwife on shift, recruitment of additional Band 7 staff was taking place and consultants have extended their daily hours of working until 8.30pm.
Mrs Acott also said: “women have a clear management plan developed by their named consultant, which is a criteria for referral. Should there be any changes in terms of: maternal observations; blood results; ultrasound scans; or fetal wellbeing, this is escalated immediately to the obstetric team on call.”
County Councillor Karen Constantine, who sits on the authority health overview committee, is calling for Mrs Acott to ‘consider her position’ following comments made in a BBC interview that there were “six or seven” avoidable deaths..
Cllr Constantine said: “It is crass and grossly insensitive to say there were ‘six or seven’ avoidable deaths. The CEO doesn’t have a tight enough grasp of the facts of the situation and her continued tenure as CEO adds insult to injury to a dramatically failing system. How can we trust in any way the word of a CEO whose track record of cover up is evident?”
She also asks why the CQC had not discovered the areas of concern earlier.
She added: “The public need action and I believe a full public enquiry is required.”
South Thanet MP Craig Mackinlay said: “The Healthcare Services Investigation Branch and the Care Quality Commission have reported quickly leading to three strands of action: Dr Bill Kirkup will head up an independent review (he has led investigations elsewhere in the country upon failings being recognised); the regional medical director and regional chief nurse are appointed to oversee clinical practices at the trust and the national chief midwifery officer with specialist team are on site to ensure standards are improved.
“What all this means, as a package, is that maternity services within the trust area are currently the safest in the country. This must remain so. Concurrently, Kent MPs have met with the Health Secretary, Matt Hancock with our demands for £350 million of capital investment across the East Kent NHS estate.”