Short-staffed neonatal unit 'should not have been operating'

The review of paediatric services at Walsall Healthcare Trust by the Royal College of Paediatrics and Child Health has highlighted a catalogue of concerns about the way the trust was running the service, including a chronic shortage of staff during a period of increased activity.

The report, published by the trust, identified serious concerns, including when nurses in the neonatal unit worked in a separate room to babies in their care with no remote monitoring and instead relied on the sound of alarms to alert them to problems.

The report said: “The review team found a service that was incredibly busy, with committed and enthusiastic staff, and not working in a sustainable way.”

It said: “[The] overall headcount is insufficient and the service has suffered from the loss of experienced staff… The absence (until recent appointments) of a specialist neonatologist on the consultant team was a significant breach of [British Association of Perinatal Medicine] standards and the unit should not have been operating as a [local neonatal unit].”

The trust, which was placed in special measures in January, told HSJ in a statement it was acting on the report and had recruited three paediatric locum consultants and was planning further recruitment of nurses this year.

The reviewers found the trust’s neonatal unit was only funded for 15 cots but was regularly operating with 18.

They also found that nurses were regularly based at a nurse station opposite the intensive care room but with no remote monitoring of babies in their care.

It said: “When visiting the unit, it was observed that the nurses do not remain in the intensive care room with the babies and that staff tended to work at the desk, opposite the door to this room. This is unusual in neonatal intensive and high dependency settings.

“When nurses were asked about this, they suggested that this was normal practice on the unit. While the desk is close to the ITU room, it does not allow visual observation of the babies and there is no central monitoring at the desk. This makes nurses reliant on alarms to alert them to deterioration in a baby’s condition and poses the risk that response to deterioration might not be as quick as it could be.”

The trust said this practice had now been stopped.

Other findings by the RCPCH team included:

• Recent restructuring has left nursing rotas with insufficient experienced staff nurses.
• Governance processes for complaints and investigations were not “sufficiently robust or thorough” to ensure lessons had been learned and changes made.
• Insufficient medical staffing for the neonatal unit “both in numbers and expertise”.
• Inappropriate reliance on advanced nurse practitioners to manage the neonatal unit.

The RCPCH was initially asked to look at seven individual patient incidents, five of which were raised with the NHS Trust Development Authority by former Walsall paediatrician David Drew.

The report said there were no concerns about the way the trust had handled the incidents.

In the published report the trust redacted all the details of the patient cases but it shared the findings with families and the full report with the Care Quality Commission and NHS Improvement.

Walsall chief executive Richard Kirby said he accepted the findings of the report, adding he was confident the wards were safe but there were improvements to be made.

He said: “We saw a big increase in activity in key departments in a short space of time and we didn’t respond to that well enough as it was happening. I would accept that.

“We have also had a culture in the trust of seeking to soldier on in the face of increasing pressure. If we are going to continue to deliver a service we need to be able to deliver it well, if we can’t we need to say so and set out what we are going to do about it.

“This report is an example of us attempting to tackle that culture.”