Introduction

Northwick Park Hospital, part of North West London Hospitals NHS Trust (the Trust) has started an inquiry after three maternity patients died within a three month period. The Trust had previously been placed under special measures after 10 women had died between April 2002 and April 2005.

T10 Maternal Deaths Within 3 Years

Between April 2002 and April 2005, 10 women died during pregnancy, or within 42 days of delivery, at the Trust. This number of maternal deaths over this period was significantly higher statistically when compared with other Trusts that served similar populations. During the period April 2002 to March 2004, the maternal death rate for the maternity unit was 74.2 per 100,000, 6.5 times the national average of 11.4 per 100,000 as reported by CEMACH (Confidential Enquiry into Maternal and Child Health). In 40% of these cases, death was caused by a failure to control post birth bleeding.

On the recommendation of the Healthcare Commission, the Secretary of State for Health imposed special measures on the Trust in April 2005. The Healthcare Commission’s investigation described a maternity service that had, amongst other things:

		severe capacity problems
		a lack of clinical leadership
		poor relationships between staff
		inadequate cover of Consultants who are responsible for overseeing care on the labour ward
		a shortage of midwives
		a lack of specialist services for women whose pregnancies were high risk.

The Healthcare Commission acknowledged that following each of the 10 deaths, the Trust did try to ensure that lessons were learnt from each death (although the Healthcare Commission also pointed out that the lessons learnt were limited).

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Progress Since April 2005

The Healthcare Commission reported that the Trust had made “substantial progress” since April 2005. These improvements included, amongst other things, the following:

		recruitment of three additional Consultant Obstetricians
		an increase in the level of cover by Consultants
		the recruitment of 20 additional midwives
		an increase in the number of supervisors of midwives in line with national guidance
		a refurbishment of the labour ward
		more effective teamwork
		ward rounds by Consultant Obstetricians three times a day
		implementation of clinical guidelines
		revision of the policy for reporting and managing untoward incidents and replacement of defective equipment.

The unit was lifted out of special measures in September 2006.

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Three further deaths within the last 10 months

Three further maternal deaths occurred between June 2007 and March 2008 at the maternity unit.

The latest woman to die was a 28 year old teacher. During delivery on 13 March 2008, she suffered a tear in the vaginal wall which later became infected with the flesh eating bacteria necrotising fasciitis. She died on 20 March from multi-organ failure caused by blood poisoning.

The Trust have confirmed that they will be undertaking a review to reassure themselves that there is no common link between the deaths.

Fiona Wise, Chief Executive of the North West London Hospitals NHS Trust said “Given that it has been 18 months since we were lifted off special measures, we feel that it is the right time to undertake a review to re-check our systems and procedures. This also gives us the opportunity to review again the three maternal deaths that the Trust had during 2007 and 2008. Two of the maternal deaths have been investigated on an individual basis and there is currently no evidence to show that there are any issues with the quality of care received in these cases.” The Trust have said that the internal review will be completed by the end of May.

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Conclusions

The Trust have certainly improved significantly since the Healthcare Commission’s report. Whether the three further maternal deaths are an unfortunate coincidence, or an indication of an ongoing problem, remains to be seen. However, what is clear is that maternal deaths are attracting media attention from the local and national press. The placing of the Trust under special measures attracted national media attention. However, the substantial improvements made by the Trust since April 2005 have attracted little attention. If you are approached by a member of the press following a maternal death, then you should speak to your legal department or a member of the Bevan Brittan team.

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