Findings of the Maternity Learning Review at University Hospitals of Derby and Burton NHS Foundation Trust

University Hospitals of Derby and Burton NHS Foundation Trust (“UHDB”) have recently engaged with a maternity learning review. The results of the review have been released today. In a 74-page report prepared by the Healthcare Safety Investigations Branch (“HSIB”) they have made a number of safety recommendations together with noting delays in care, staff shortages and bullying.

The review was instigated following a number of maternal deaths and maternal collapse events that happened at UHDB between January 2021 and May 2022. The focus was on 7 individual cases however the HSIB considered the wider ongoing practices with obstetrics at the Trust, including staffing and patient experience. The 7 cases include 3 mums and a baby who died, together with 4 further mums suffered serious complications such as heart attacks and the need to be resuscitated.

Whilst the report was designed to reassure the families involved, the HSIB conclude that “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 HSIB have made 5 recommendations, 10 safety prompts and 26 findings. We believe that the issues are ones which have been present for decades.

Karen Reynolds, Head of the Clinical Negligence team in Derby commented “I have been pursuing obstetric claims against the Trust for 30 years so I am afraid to say that the report contained no surprises for me and my team. These failures have a catastrophic impact on families at a time that should be joyous. The failure to heed external reviews and learn lessons is incredibly depressing. When will things change? I think what is comforting is that the midwifery teams were quite candid in some of their comments to the review team and hopefully this will lead to change. It is so important that Trusts and their employees are honest and transparent when mistakes are made. Unfortunately, it is often only when solicitors are instructed that the families receive the answers that they deserve.”Having considered the findings of the HSIB we note there were several areas of concern:-

Poor Leadership

Since the trust merger in 2018 there is reported to have been a prolonged period of fragmented leadership. With indirect influences on accountability and the acceptance of poor behaviour noted there has been difficulty with leadership of teams. With certain roles being considered ‘a poisoned chalice’ there are challenges to make effective change.

The 7 cases forming part of this review were all emergency situations and the HSIB found that in the majority of cases it was unclear as to whether there was a senior member of the team providing an ‘helicopter view’ as to care. Staff confirmed that in emergency situations in theatre the scene would often be ‘chaotic’ with confusion as to whether protocols were activated and staff allocated to tasks.

Duty of Candour

Families who have experienced a significant event around the time of birth reported that they felt whilst they were in hospital the staff were kind and supportive once discharged home, they were left in the dark about the reasons surrounding their experience. They were not supported in understanding the events they had experienced and felt “abandoned” by the trust during the postnatal period.

The HSIB believed that meeting with those affected after a critical event is vital for the family but also for the Trust to enable learning.

Lack of Respect and Bullying

Whilst there were examples of “kind and supportive” communication to families the HSIB learned that there were significant issues between the clinical teams. There was a perception of obstetric hierarchy with some obstetricians appearing dominant over other specialities. Evidence was found of unkind words, demeaning behaviour and bullying treatment of colleagues particularly from within the obstetric body towards the midwifery and anaesthetic workforce. We are currently instructed by many women in respect of historic gynaecological treatment at the Trust provided by Mr Daniel Hay. In a many number of these cases we have heard of difficult language and challenging working being prevalent at the Trust so it is of no surprise that a culture of bullying has been identified.

Staff have commented that poor behaviour was often displayed during meetings and handovers, complaining of being shouted at or being made to feel small. In one case it was stated “There is a tier of obstetricians that are very experienced, knowledgeable and have been here a long time but some of their practice is out of date…” .

Lack of Communication

In recent years the matter of informed consent has been bought to the forefront of maternity care. A patient should be fully informed about their care and choices. Problems with communication between patients and the Trust has been identified within the report and there are examples showing non-engagement with and an unwillingness to involve the women and their families in decisions about their care.

We acted in the landmark case of Webster v Burton Hospitals NHS Foundation Trust (prior to the UHDB merger) where it confirmed that there is a legal duty on medical practitioners to take reasonable care to ensure that a patient is fully aware of maternal risks of injury inherent in any proposed course of treatment and the availability of any reasonable alternative treatment. It is a shame to note that patients are still finding it difficult to communicate with staff about their treatment.

Failure to Learn

Between April 2019 and November 2022 the HSIB have provided 82 safety recommendations to the Trust as a result of individual case maternity investigation reports. It is not clear that the Trust implemented any of them.

It was also noted that prior to the summer of 2022 the review process undertaken by the Trust was a “closed process, inconsistent and held erratically”. This led to assumptions being made on behalf of people who were not invited to participate in the safety reviews.  More recently there appears to be a new approach to governance within the Trust with an effort to move away from blame.

However it is clear that there has been a period of failure by the Trust to fully acknowledge the rising concerns within the maternity services in the region.

Within the review they noted several examples of inadequate learning. Evidence was given stating there was “poor sharing of learning opportunities” and there was a “slow response to incidents and complaints and [a] lack of respect” for external reviews and the HSIB maternity investigation reports.

Staffing Levels

It was of no surprise to note that the staffing levels within the maternity service at the Trust were challenging. Whilst the review confirmed the challenge faced with staffing, the HSIB felt that it did not directly impact the outcome of the 7 events under investigation. However, an impact was felt with one patient commenting that they felt that it would be hours before someone would be available to discuss matters and staff commented that they were concerned staffing levels were impacting their ability to deliver safe care.

Whilst the Trust advise that posts are being filled currently with more on the horizon those accessing care at this time will be concerned as to whether their obstetric care will be safe.

Clearly the identified culture problems will not assist recruitment and retention of staff.

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If you have had a poor experience or been affected by sub-standard maternity care at University Hospitals of Derby and Burton NHS Foundation Trust or elsewhere, you are welcome to contact our team to discuss how we can help and support you:

• Karen Reynolds, Partner (Derby/Stoke on Trent/Birmingham/Manchester/Liverpool) on 0345 272 5677 or by email to karen.reynolds@freeths.co.uk
• Siobhan Genever, Director: 0345 030 5774 or 07971 586185 or by email to siobhan.genever@freeths.co.uk
• Ibrahim Mahmood, Legal Assistant: 0345 126 4359 or by email to Ibrahim.mahmood@freeths.co.uk