‘Chaotic’ maternity service was warned of same problems years earlier

Not identifying serious incidents and being slow to start inquiries: A serious incident inquiry into Bethan’s death was not started for nearly four months, and the trust’s initial investigation found it did not meet the criteria for one. The 2022 ombudsman’s report was particularly critical of this, saying an SI investigation should have been started within two days, and recommended the trust ensure they happen “in a timely manner”. But the CQC report showed there was still a three-month delay in deciding to declare SIs into baby deaths, and that some cases were inappropriately downgraded from SI.

The trust told HSJ: Adverse and serious incidents are subject to the same timescales, and a rapid response report is presented to a “serious incident declaration meeting” within 72 hours to determine what is required. The timescale can be longer if an incident is upgraded from “adverse” to SI, which happens when additional evidence is presented. Since the CQC inspection, we have made changes to the way we categorise incidents in maternity.

Inadequate cardiotocography monitoring and interpretation. NICE guidance calls for monitoring every five minutes during the second stage of labour but Bethan’s was not monitored for 10 minutes when she was first admitted – despite concern that her mother’s waters might contain meconium, which can indicate a baby in distress. An external review ordered by St George’s at the time recommended a change to its guidelines, but the CQC this year found “staff review of fetal monitoring in labour was not safe”, and was critical of audit results of CTG reviews and the trust’s failure to act on these results. The CQC noted the trust had been aware of this safety concern in 2018 and “it was not clear why inconsistent review techniques were still being used by the service in 2023”.

The trust says: We have made changes to our processes in response to the recommendations. As detailed in the CQC’s report and following their inspection, we have made a number of improvements to address CTG issues. These include upgrading CTG monitors, establishing a central CTG monitoring system within the induction of labour area, conducting an annual training review to incorporate learning, and acting as the host of a national maternity multi-disciplinary training programme.

Not learning from previous incidents. The 2019 prevention of future deaths report into Bethan highlighted the issue of learning, with the coroner commenting on how little had changed a year after her death and that there was “little evidence” that “effective reflection, reflective discussion or learning had taken place”. At the time the trust said it was ”very sorry that the important learning issues and improvement actions… were not conveyed effectively during the oral evidence” and that it was “fully committed to learning from incidents”.

But the CQC echoed concerns about lack of learning, saying there were gaps in evidence of learning from audits and a lack of plans for improvement and learning. The CQC report also says, in an apparent reference to Bethan’s death: “Improvements required in practice were identified following the serious incident of baby death in 2018: CTG interpretation, handover of care, learning lessons from poor outcomes, and investigating incidents in a timely way. During the inspection, we found these recurring themes were ongoing within the service nearly five years later.”

The trust says: In response to the [2019 prevention of future deaths] report’s observation of potential missed learning opportunities, we want to reiterate that the incidents underwent a thorough clinical review. A rapid response report was presented to the SIDM for appropriate assessment. The rapid response report identifies any immediate care concerns and learning and identifies the immediate safety actions to be put in place, by who and by when. We have taken measures to ensure that learning from incidents and the insights gained are actively integrated into ongoing learning and development throughout the whole service.

Not following national guidance and recommendations. Bethan’s mother was not offered a “sweep” – which can start labour – when she was 40 weeks pregnant, despite National Institute for Health and Care Excellence guidance that it should be offered. A midwife told her the trust did not offer them. In the CQC report, several trust policies were at odds with national guidance or recommendations including continuing with the “continuity of care” policy despite “extreme” staffing problems; not having supernumerary staff to give a “helicopter” view of acuity; and fundal height monitoring of pregnant women.

The trust said: We have changed our sweep protocol to 40 weeks. Pausing continuity of care is not national guidance, but a recommendation to support safe staffing, and we continued with it to address health inequalities, which is subject to regular review. Because of shift patterns, stopping CoC would not result in more staff in the delivery suite. We acknowledge that we do not use customised growth charts or conduct symphysis fundal height measurements to monitor fetal growth. The service uses ultrasound scanning as an alternative. This has been discussed and approved at board level and with external bodies.