PERFORMANCE: There has been another maternal death at Homerton University Hospital Foundation Trust.
The hospital has now had five maternal deaths in 18 months.
The death, which occurred in January, has been referred to the coroner and will be investigated as a serious incident by the trust alongside external clinicians - a consultant obstetrician, a consultant anaesthetist and a senior midwife.
In a report to the trust’s February board meeting, chief executive Tracey Fletcher said: “Sadly, the trust has recently had a further maternal death bringing the total to five in the past 18 months.”
After an internal investigation into the deaths the trust said that each of the previous four deaths had been “different, with no obvious similarities”.
The trust said it is seeing more high risk mothers because there is a rise in women having babies who have clinical complications. High risk women are being referred to Homerton because it has a tertiary level neonatal intensive care unit.
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The trust had already asked the London clinical senate to investigate the four previous deaths. Its recommendations are outlined in City and Hackney Clinical Commissioning Group’s February board papers.
- using an interpreter for women who may require one;
- a postnatal plan of care for women with blood loss of more than one litre;
- all staff should participate in multidisciplinary skills and drills sessions for the management of major obstetric haemorrhage; and
- training to recognise sepsis should be undertaken by all clinical staff.
A group of staff calling themselves the “unhappy midwives” anonymously raised concerns with the Care Quality Commission in 2012 over the leadership of the maternity unit.
However, a CQC inspection last February rated the maternity department as “good” and failed to find any basis for the concerns raised.
City and Hackney CCG recently completed its own review into the four deaths.
The CCG found that in 2013-14 Homerton accounted for 16.6 per cent of maternal deaths in London but only 4.5 per cent of births.
A report in the CCG’s February board papers stated: “Maternal deaths appear very high at Homerton Hospital for 2013-14 but there is a need for more data covering a longer period of time as clusters do occur.”
Commissioners compared Homerton to Barts Health Trust’s Royal London Hospital and found that Homerton has fewer serious incidents in most categories.
The review also concluded that the trust has the highest reporting rate in north and east London, which could mean that it “may appear to have more maternal [serious incidents] when compared to other trusts”.
Homerton board papers