Four days after arrival in post, new trust chief executive Mary Wells found herself working with a crisis team sent in to turn around a maternity unit in serious trouble. Eighteen months later, Daloni Carlisle hears what was wrong and how it was tackled

Four days after arrival in post, new trust chief executive Mary Wells found herself working with a crisis team sent in to turn around a maternity unit in serious trouble. Eighteen months later, Daloni Carlisle hears what was wrong and how it was tackled

When Mary Wells took over as chief executive of North West London Hospitals trust in April 2005 she knew there was a big problem with the maternity services. But even she did not realise just how serious the situation had become.

From 2002-05, 10 women died during or shortly after giving birth at the trust's Northwick Park Hospital, pushing the maternal mortality rate above 70 per 100,000 births - around seven times the national rate.

Investigations were under way and it was clearly a priority area for the incoming chief executive. Then, four days after she arrived, the Healthcare Commission recommended special measures and called in an external team to, in its own words, 'safeguard women at Northwick Park Hospital's maternity unit'.

'I knew the Healthcare Commission had taken up an investigation,' says Ms Wells from her office some 18 months later. 'I knew there was an action plan. I knew it was going to be a priority. But special measures? No. It was a bolt out of the blue.'

It's been a rollercoaster ride since then as trust management, senior clinicians and a team of experts struggled to turn around a highly dysfunctional unit into a safe place to give birth.

Special measures were finally lifted on 22 September of this year (although bi-monthly monitoring by NHS London continues) and on a blustery day in November, Ms Wells and her top team took time to look back over the past year and a half.

Even today there is a slight feeling of rabbits being caught in the headlights. Everyone, it seems, knew there was a problem. But no-one was able to take full control of the situation.

Dr Onsy Louca, a consultant obstetrician at the hospital for 10 years and now clinical director of maternity services, recalls his feelings at the time of the deaths.

'There was a refurbishment of the maternity unit under way and at the same time the merger of a smaller unit with our main unit,' he says. This was the high-risk maternity service at Central Middlesex Hospital. 'It made us worried whether we could cope. It was a bit like inviting another family to live with you and trying to renovate your house at the same time.'

'We were very short staffed,' adds Colette Mannion, the head of midwifery, who joined the trust in 2004. 'We lost staff with the merger because they were not prepared to bus across London.'

The unit's midwifery vacancy rate was 27 per cent, against a norm in London of around 11 per cent.

Relationships between obstetricians and midwives had broken down, admits Ms Mannion. 'It was like continuous crisis management,' adds Dr Louca. 'There was very little time put aside for planning or sociability.'

Under investigation

Dr Louca in particular had pushed for the trust to call in the Healthcare Commission but this was stalled by an internal investigation that was simply not up to the task. 'We had an action plan,' adds Ms Mannion. 'But it was nowhere near far reaching enough.'

The Healthcare Commission carried out two investigations and published two reports. The first, published in July 2005, looked into the systems failures that led to the deaths, identifying lack of leadership and weak risk management. The second - and far more sensational in media terms - was published in August 2006 and looked at the impact of these weaknesses on the 10 women concerned. It examined how and why they died and makes extremely uncomfortable reading.

The unit had neither the staff nor the skills to deal with the high-risk caseload at the hospital, it said. Consultant cover was below national guidelines and consultants did not routinely visit wards when they were on duty.

There was an excessive reliance on junior medical staff, who were left to make their own decisions about care in complex cases. They did not always get it right.

There were too many locum and agency staff, who did not always get the necessary guidance or support. Managerial leadership was weak and teamwork dysfunctional.

When deaths occurred, the response focused on the medico-legal issue. A single member of staff was responsible for co-ordinating all aspects, from preparing the coroner's brief to liaising with families. 'As a result,' says the report, 'learning from the deaths was not as effective as it should have been.' Mistakes were repeated.

Ms Wells, Dr Louca and Ms Mannion are not in the business of conducting yet more post-mortems but want to share their experiences. At the risk of being accused of making a virtue out of a necessity, Ms Wells calls special measures 'an opportunity realised'.

'It was very tragic,' she emphasises. 'In all this, 10 women died. The important thing in the changes we have made was to create a unit in which that scale of tragedy cannot happen again.'

Under special measures, the trust agreed a 29-point action plan with the Healthcare Commission and brought in a team of external experts, namely midwives Mai Buckley from Barts and The London trust, Pat Wooster from Ealing Hospital trust, Andrew Lingen-Stallard from King's College Hospital trust and Julia Savage from Nottingham, as well as Professor Sabaratnam Arulkumaran, vice-president of the Royal College of Obstetricians and Gynaecologists. The national clinical governance support team came in to review the structures.

Deliveries were capped at 4,700 (as against more than 5,000 previously) and women with elective Caesareans were given a choice to transfer elsewhere.

There was money to employ 20 more midwives and three consultants for a year. 'Given that resources were a key part of the problem, the money that came with special measures was very important,' says Ms Wells.

Immediate changes

The external team was very much hands on and had daily contact for at least four months. Some even worked shifts on the unit. They immediately began to make changes, introducing meetings for staff - daily, weekly and six weekly, each with a different focus. Midwives, obstetricians and managers began to talk to each other.

New multidisciplinary training programmes got off the ground and audit was embedded in routine. All clinical guidelines were rewritten, circulated to all clinical staff and placed in all clinical areas and on the trust's intranet.

'You can say all that in one and a half minutes,' says Ms Wells. 'But it was a huge piece of work.'

A new clinical governance structure was developed with a series of committees feeding into a central maternity governance board that includes women's partnership groups, clinical risk management, guidelines and audit and supervision of midwifery.

'All the groups have terms of reference and they are all CNST [clinical negligence scheme, for trusts] compliant,' says Ms Mannion. There is even a dedicated clinical risk midwife.

As leaders, they all had their own contribution to make. 'We were all in seven days a week for the first six months [of special measures],' says Ms Wells. 'We were walking the wards, making sure we were visible and accessible to staff. I think this is one of our top tips.'

When the reports came out, they were on hand again. 'Some of the midwives were here when the women died and it was very important to support them and have open communication,' says Ms Mannion.

The feeling in the maternity service now is quite different, say Dr Louca and Ms Mannion. For one thing the£19m refurbishment is complete, providing pleasant surroundings for women as well as top-notch clinical facilities. The modern interior with charming pictures of mums and babies on the walls is in stark contrast to the 1970s concrete building that makes up the rest of the hospital.

More than that, it is calm and controlled. There is time for audit and reflection on practice as well as regular and thorough analysis of untoward incidents. Complaints are down; patient satisfaction surveys are getting good results. There are closer relationships with local primary care trusts.

'We are suddenly a very attractive place to work,' adds Ms Mannion, pointing out that midwifery vacancy rates are down to 6 per cent. 'I asked one of our new midwives why she came here and she told me it was because she felt this was a place where she could make a difference.'

Dr Louca adds: 'We used to advertise junior doctor posts and get no applicants. Now we get 10 or 20. I can't remember the last time I saw a locum.'

Patients' virtue

The most difficult area to turn around has been patient involvement. On a practical level, the trust has contracted an interpreting service offering 200 languages and translated leaflets into the six most common languages spoken in its catchment area. It has set up a women's partnership to try to gain the insights of local women and worked with the local racial equality council on specific issues.

But still Ms Wells feels there is a long way to go. 'We are trying to engage a very, very diverse community. It's turned out to be one of the most difficult areas.'

Much of what they have learned could usefully be noted elsewhere; indeed when the Healthcare Commission published the second report it asked all hospitals to review their risk strategies. It is planning a review of maternity services in 2007.

Ms Wells is reluctant to say that other units should be breathing a sigh of relief, saying she can really only talk about the confluence of circumstances that beset Northwick Park. Merger of maternity units is a topical issue on which she will give advice, however. 'Make sure you have got enough space to deliver the service. Make sure when you recalculate your staffing levels you have the correct ratios of midwives to women and consultant numbers.'

Another area is being open. 'I think one of the things we have identified and that is not unique to this unit is how inward looking we had become,' she says.

'Having a more structured programme in which senior staff from other organisations come in here and bring good practice and ways of doing things from other places is one of the most important things that came out of this. It's something we will try to continue, not least by talking about what we have learned.'

Towards the end of their reflections, Dr Louca, Ms Wells and Ms Mannion seem a little overwhelmed and start a love-in, praising each other's leadership and contribution, thanking everyone involved, before snapping back to professional mode.

'It's all about remembering that the women have to be at the centre of it all and that we work in partnership around them,' says Ms Wells. 'We don't always get it right but we strive to get it right all the time.'