The Healthcare Commission has reminded all NHS trusts to check they have 'robust systems' for monitoring the safety of maternity units following its report into the deaths of 10 women who gave birth at Northwick Park Hospital, London.

The Healthcare Commission has reminded all NHS trusts to check they have 'robust systems' for monitoring the safety of maternity units following its report into the deaths of 10 women who gave birth at Northwick Park Hospital, London.

The women all died during pregnancy or within 42 days of giving birth in the five years to April 2005.

Common factors included insufficient input from a consultant or a senior midwife, with difficult decisions left to junior staff; failure to respond quickly when a woman's condition changed unexpectedly; inadequate resources to deal with high-risk cases; too few consultant obstetricians and midwives; not enough dedicated theatre staff; and over-reliance on agency and locums without adequate support.

The commission said the trust's management failed to learn from early tragedies, thus allowing mistakes to be repeated.

'The board was aware of the high number of deaths and should have acted sooner to rectify problems,' the commission said.

North West London Hospitals trust, which runs Northwick Park, was put under special measures when the commission was notified of the high death rates in April last year. Although it remains under special measures, the commission's report noted 'significant improvements in maternity services now provided there'.