5 BABIES DIE IN BLUNDERS AT NHS HOSPITAL
Health chiefs apologise over ‘avoidable’ tragedies at troubled unit
THE NHS has been forced to apologise for the ‘potentially avoidable’ deaths of five babies at one hospital.
In the latest scandal to engulf Scotland’s maternity services, evidence has been uncovered of poor care in cases where babies were either stillborn or died soon after birth.
A new report into the deaths at Caithness General Hospital found key signs of illness were missed, midwives delayed seeking specialist help and there was a lack of proper supervision during labour.
Last night, NHS Highland offered an ‘unreserved’ apology to the families involved.
The shocking revelations come only days after it emerged six babies died ‘unnecessarily’ at Crosshouse Hospital in Kilmarnock, Ayrshire.
The Scottish Government was accused of ‘sleepwalking through an NHS staffing crisis’ and faced calls to act swiftly to prevent further tragedies.
The damning 128-page report into neonatal and maternity services at Caithness General Hospital, seen by The Scottish Mail on Sunday, will be discussed at the next meeting of the Highland NHS board on Tuesday.
NHS bosses will recommend the maternity unit is downgraded to a midwife-led service for ‘low-risk’ mothers, while more complex cases should be referred to Raigmore
Hospital, 100 miles away in Inverness, where there is 24-hour specialist cover and high dependency care.
A major review into the Caithness maternity unit was ordered after a two-day-old girl died of blood poisoning in September last year.
Medics failed to spot the early signs of sepsis infection, caused by E.coli. The subsequent delay in seeking specialist help contributed to her death, according to an external inquiry.
‘Sub-optimal care’ and ‘avoidable factors’ were also found in four other perinatal deaths at the hospital between 2010 and 2015.
One young mother classified as ‘high risk’ suffered a stillbirth when ten days overdue after the health board could not find a bed for her. Another gave birth at home and lost her child after there was ‘no recognition’ of the risk of pre-term labour. These were the findings of an investigation by the infant mortality and morbidity studies department at the University of Leicester, which formed part of the review.
Last night, NHS Highland medical director Dr Roderick Harvey – who led the Public Health Review – ‘apologised unreservedly’ for the ‘failings’ at Caithness General Hospital.
‘Deficiencies did not reflect on individuals’ Where we were aware of any deficiencies we have of course said sorry... deficiencies did not reflect on individuals but rather the system Dr Roderick Harvey
He said: ‘The families have been uppermost in our minds when conducting the review.’
‘Families do rightly put their faith in the health service to keep mothers and babies safe and the fact that infants died possibly as a result of sub-optimal care is unacceptable.
‘Having identified real safety concerns, in my view we must move swiftly to address these concerns.
‘We have been in touch with all the families affected offering to meet, and some have taken us up on that offer. Where we were aware of any deficiencies in care we have, of course, apologised.
‘The reviews were clear that any identified deficiencies did not reflect on individual clinicians, but rather the system that they work in.’
Recommending that the Caithness maternity unit be downgraded to a midwife-led service, he added: ‘The majority of the problems identified by the review would not have occurred, or could have been managed more effectively at an earlier stage, had the unit operated as a midwife-led community maternity unit.
‘In general, such a policy would have forced emerging problems to have been escalated at an earlier stage, thereby ensuring that both mother and baby would have been in a more appropriate and safe environment prior to delivery.
‘Continuing to provide obstetric interventions in the absence of specialist paediatric/newborn support will inevitably result, sooner or later, in more avoidable perinatal deaths.’
It is also recommended that the services at Raigmore are ‘strengthened’ to cope with the additional numbers of mothers and babies.
There are 230 births in the Caithness area every year, of which 140 to 160 are in the general hospital.
The Caithness unit has locallybased obstetricians and midwives but has no paediatricians, advanced neonatal nurse practitioners or onsite adult intensive care facilities.
As part of the Public Health Review, internal and independent external investigations were undertaken. The
review found there was an ‘apparent lack of awareness of the opportunities for earlier transfer to Raigmore maternity unit and opportunities for greater teamwork and leadership’.
There were also ‘major recruitment challenges to medical, nursing and midwifery posts’ due to the unit’s isolation and a ‘difficulty in keeping up skills’ because of the small patient numbers and the lack of opportunity for regular training.
Since the review following the death of the infant in September last year, interim safety measures in place mean first-time births and all elective Caesarean sections take place at Raigmore.
Dr Harvey said: ‘All our rural general hospitals have challenges with staffing. In Caithness, a huge amount of work is ongoing. New approaches include a rotation of consultants from Raigmore to Caithness.’
Public Health Minister Aileen Campbell said: ‘We are aware of the report into the safety of Caithness maternity and neonatal services commissioned by NHS Highland.
‘The chief medical officer supports the findings of the report on clinical grounds and we welcome the work by NHS Highland to engage with local people in Caithness in advance of publication and a final decision being taken.
‘It is imperative that we deliver safe, high-quality services to pregnant women and newborn babies and that when adverse events happen, we reflect and learn lessons to ensure they are never repeated.
‘Our deepest sympathies go out to the families whose experiences are reflected in the report, who have suffered pain and loss at what should have been the happiest time in their lives.
‘We want to ensure that every woman and baby in Scotland gets the best maternity and neonatal care.
‘That is why we initiated a review of maternity and neonatal services across Scotland which will report to Ministers shortly.
‘We would expect NHS Highland to take full account of the outcomes of that review, when it publishes, in how it delivers its care in Caithness.”
Bereaved parents have called for a public inquiry into the deaths at Crosshouse between 2008 and March this year. Health Secretary Shona Robison has ordered a review by Health Improvement Scotland after concerns were raised it was ‘understaffed and overworked’.