Two mothers and baby died following childbirth at Royal Derby Hospital, report finds

Royal Derby Hospital

Warning: Some readers may find the following maternity review report difficult to read

Two mothers and a baby died and four further mothers suffered extreme consequences during and following childbirth at Royal Derby Hospital, a new report has disclosed.

A new independent report from the Healthcare Safety Investigation Branch, publicly released by the University Hospitals of Derby and Burton NHS Foundation Trust, covers seven cases involving pregnant mothers and their babies.

Issues with communication, staff shortages, a bullying culture between teams caring for mothers and babies, and delays to care are among the issues within the cases of the seven mothers – leaving the surviving parents and families traumatised and frustrated.

The incidents involving the seven mothers and their babies took place over the course of 16 months from January 2021 to May 2022, and involved mothers aged 28 to 42, with six cases wholly taking place at Royal Derby – three in gynaecology theatre and three in labour ward theatre – and one starting at the patient’s home.

The review found:

  • A mother and her baby both died after the mother had a heart attack at home, with delays in Royal Derby staff calling for emergency support

  • A mother who died following the birth of her child had waited 57 minutes for an essential blood transfusion

  • A mother cannot remember the birth of her child after complications during the procedure, she is in disbelief that the trust discharged her home without telling her “anything” about the issues she faced

  • A mother did not hear from the trust for four months after she was discharged from intensive care, suffering complications during childbirth

  • A mother says the trust’s support has been “awful”, with no memory of her incident after having a heart attack following childbirth, with the unexplained incident leaving her too scared to walk down her road

Royal Derby Hospital Credit: PA Images

While the investigation, which was actively requested by the trust, reports that it did not find any common themes that affected the “outcomes” of all seven cases, it did state two “crucial areas of safety improvement that require prompt action” to help protect further mothers and their babies.

It concludes: “It is not possible to know if a different approach to safety investigation and implementation of learning, or a different safety culture within the maternity unit could have influenced a different pathway of care prior to the critical events.”

The first area of prompt improvement was the management of major obstetric haemorrhage – severe bleeding, the leading cause of maternal deaths – including the very process of calling for help and which staff should be required for expert action.

This includes confusion over the number to call within the hospital to alert staff to an emergency situation requiring specialist support.

Meanwhile, the process of handling a major obstetric haemorrhage did not include a joint alert for emergency blood supplies to be delivered to the operating area.

If emergency blood supplies were required, staff had to send a separate alert to the blood bank on site.

This process had involved a member of staff heading to a different floor of Royal Derby Hospital and returning with the blood supply, which can take “up to 20 minutes for a round trip”, the report says.

In one mother’s case, a call for help relating to a major obstetric haemorrhage was made 30 minutes after an alert for emergency blood supplies was issued.

It stressed that the second area of improvement related to communication, saying: “Whilst there was evidence of kind and compassionate care whilst the women were in hospital, the review learned that once the women and/or families had been discharged from the hospital the communication was ‘unbelievably poor’.”

This included an apparent “unwillingness” to involve women and/or their families in decisions about their care, the report says, with “limited” evidence of follow-up support after discharge, leaving families feeling “abandoned”.

The report found that there is a shortage of staff to help care for mothers and babies, both in maternity and gynaecology departments, with it being common for a postnatal midwife to be looking after eight or nine women and their babies.

Staff told the investigation that they were concerned about burnout and that they were “very tired”.

Widespread vacancies and difficulties in both recruitment and retention are national issues which are being felt locally, throughout each department, the report makes clear.

It says that there were 45 full-time equivalent vacancies out of a potential total workforce of 379 full-time equivalent midwives.

The report says there was evidence that the midwifery shortage “impacted on the experience of the women and/or families involved” but not directly on the outcomes of the seven cases. It found that staff “were passionate about providing a high-quality service for women and most of them pulled together to support one another”.

It details wider issues throughout the trust, including staff having “little confidence” in the maternity governance process, and that a “kind and compassionate culture was not universally reflected in all of the senior team”.

Meanwhile, the role of lead obstetric anaesthetist was described by staff as a “poisoned chalice”, the report says.

The report details evidence of “unkind words, demeaning behaviours and bullying treatment of colleagues particularly from within the obstetric body towards predominately the midwifery workforce and other disciplines (e.g. anaesthetics)”.

“Staff did not feel psychologically safe and the way we treat each other is not great,” the report details.

It found there was a “perception” that communication to and from the trust’s executive board was “not strong” with some leaders feeling there had been “little executive support” surrounding the seven cases and investigations and escalations associated with them.

All seven cases have been referred to as “events” in the review report, numbered one through seven, which we have renamed “mother and baby”.

Mother and baby one:

A 28-year-old mother had a cardiac arrest while 31 weeks pregnant at her home. Her baby was born after staff took action to force the birth but the baby died two days later.

The mother was taken to hospital, with resuscitation attempts continuing. However, an obstetric emergency call was not put out by emergency department staff because they were “not familiar with the process”, which led to a delay of an “urgent senior obstetric review”.

The mother subsequently died. The family of the mother told the review that she felt she had not been listened to by staff at previous appointments, feeling as if she did not matter and the focus was just on the baby.

Mother and baby two:

A 36-year-old mother had a large vaginal bleed at home when she was more than 37 weeks pregnant. Emergency services were called and she was taken to Royal Derby by ambulance, with further bleeding identified when assessed at the hospital, at which point staff carried out a C-section.

Following the birth of her baby, the mother’s condition “deteriorated” with continued blood loss followed by a heart attack.

There was a delay in the “administration of required blood products”, with the first unit of blood given 57 minutes after admission, due to confusion over when the emergency alert was sent out for a major obstetric haemorrhage.

The mother subsequently died. The family of the mother told the review that staff had been “kind, supportive and visibly upset” at the time of the incident but received no information from Royal Derby after that, with “minimal information from a separate hospital providing support for the baby.

“I was so unsure of what I needed to do, did I have to sign anything about my wife’s death? It was terrible,” the mother’s partner told the review.

Mother and baby three:

A 30-year-old mother had an elective C-section birth at 39 weeks but immediately following the successful birth of the baby, the mother had a heart attack.

Staff attempted to resuscitate the mother but this was “unsuccessful” and the mother died.

The review details that the mother’s family thanked staff for saving the baby, saying “he is a very happy, healthy baby, 50 per cent of this story is this little guy”.

The said staff made the mother feel at ease and relaxed in the initial consultations.

Mother and baby four:

A 31-year-old mother was booked in for an induction but this was unsuccessful over three days, leading to a category three emergency C-section.

Following the successful birth of the baby, the mother had an “unexplained” heart attack and resuscitation started.

The mother was transferred to intensive care for ongoing support and remained in hospital for seven days before she was discharged back to her home.

She continues to experience “significant health issues” and requires specialist support, the report says.

The mother says she has no recollection of her time at hospital but her family said staff were “brilliant”.

However, they said hospital staff visiting the mother for aftercare had “no information” about the severity of the case and family members “kept having to repeat it”, which “caused more trauma”.

An internal investigation was carried out but the mother and her family were never told the results, until they were contacted about this new, second investigation.

The mother told the review: “I was 32 and my heart had stopped. I am so scared to even walk down the road in case it stops again.

“I have no idea why this happened and the support from the trust has been awful…I feel the trust could have offered so much more support following such a traumatic incident.”

Mother and baby five:

A 42-year-old mother had an arranged C-section at just over 39 weeks into her pregnancy due to the baby’s breech presentation.

During the C-section, the mother’s heart rate “significantly slowed”, but improved following medication, and both the mother and baby survived.

The mother was taken to the intensive care unit for further support and was discharged five days later.

She told the review she did not hear from the trust for four months.

She too said she was not told of an internal investigation which was carried out into her and her baby’s care until this new review.

Her partner told the review that they were moved to a separate room with the couple’s baby for five hours while staff tended to the mother, without any update on her condition, which they said was “distressing”.

Mother and baby six:

A 29-year-old mother’s waters broke at 36 weeks and contractions started. During labour, there were concerns for the baby’s heart rate and the mother subsequently collapsed and had seizures.

Following treatment for the seizures, the baby was born successfully through an emergency C-section, with both the mother and baby surviving.

The mother stayed in intensive care for 13 days and experienced “neurological complications” and was also treated for an infection.

She stayed in hospital for a further 27 days after being discharged from intensive care.

Following her return home, she continued to receive neurological support and rehabilitation.

She told the review: “I was just sent home with no idea what happened to me…I still can’t remember what happened.

“It’s really bad… how can they just send you home and not tell you anything? My [family member] keeps having to remind me of things and I have to have a whiteboard to remind me to do really basic things…What if this happens for the rest of my life?”

Mother and baby seven:

A 37-year-old mother had an elective C-section arranged for just over 39 weeks into her pregnancy, but suffered a heart attack during the birth and sustained “extensive internal trauma” during resuscitation attempts.

This trauma required additional surgery at a “major trauma hospital” and she remained in intensive care for three weeks, before being discharged home with home care support.

She told the review that the midwives were “very kind and compassionate”, their baby was brought to her partner quickly and they were provided with their own room.

Dr James Crampton, the hospital trust’s executive medical director, said: “The seven incidents have had a longstanding impact on the families involved, so it was paramount to us to ensure we had utilised every possible opportunity for further learning and why we proactively requested this independent review.

“Although the review did not find any common themes that impacted on the outcomes for all the women involved, there has been learning for us an organisation which we have taken very seriously, and the recommendations are invaluable in helping us to further improve safety and the experience of women under our care.

We have already addressed the report’s immediate recommendations, including refining our existing major haemorrhage guidance and enhancing our emergency bleep process, and have put a comprehensive plan in place to rapidly deliver all other initial actions within the next three months.

“We would like to reiterate our apologies to the seven women and families for the experiences they had and we thank them for their strength in sharing their feedback, which we will commit to using to improve the experience and care we provide to others.”

The trust says it is revising its major obstetric haemorrhage guidance, is looking to increase bereavement support roles and hire a family liaison officer, and had ordered a blood fridge.

Outside of the review it says it has offered roles to 18 overseas midwives, and two new consultants will start in February and March, along with “retention midwives” aimed at supporting the development staff at the trust.

Last year, 5,850 babies were born at Royal Derby Hospital.