'We are deeply sorry': Derby hospital trust apologises after baby deaths review finds care issues
“We could and should have done better, we are deeply sorry”, Derby’s hospital trust has said after a review into more than 150 baby deaths found numerous “care issues” which may have affected their losses of life. The Local Democracy Reporting Service can exclusively reveal details of a new report from the University Hospitals of Derby and Burton NHS Foundation Trust into perinatal deaths.
Perinatal deaths include babies from the start of pregnancy up to one year old, largely comprising stillbirths and complications during pregnancy and birth. The report focuses on 157 babies who died at the hospital trust in the three years and three months from January 1, 2020, through to March 31, 2023.
This review was triggered last year by the trust having stillborn and perinatal mortality rates which were significantly above the national rate – rates which have now both fallen to below the national average. Since then the trust’s maternity units at both the Royal Derby Hospital and Queen’s Hospital in Burton have been rated “inadequate”, the lowest possible rating, by health watchdog the Care Quality Commission.
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The report details 168 overall perinatal deaths, with 99 related to stillborn babies, 56 were neonatal baby deaths (first 28 days of life) and 13 were “late fetal losses”. Of these, 11 babies were born at the trust but died elsewhere, after being transferred, with the report focussing on the remaining 157 babies. It reports that in a number of the cases reviewed “care issues” were identified which “may” or were “likely” to have changed the “outcome” for the babies who lost their lives.
In 112 cases where the care of the mother and baby up to the point her baby was confirmed as dead was reviewed, care issues which “may” have affected the outcome for the baby were found in 16 cases, with a “likely” impact in 11 further cases. The report also found that 24 families, all in 2020, were not contacted to take part in reviews relating to their baby’s death. The trust has now contacted these families to find any potential lessons or concerns which need to be addressed, offering direct apologies.
It found several recurring themes throughout the investigation of the 157 cases, including an overarching assessment of the trust’s “scattergun” approach to enforcing lessons to be learned from failures, including baby deaths. The report, carried out by an independent midwife, details: “Whilst there are many opportunities for sharing learning across maternity services the learning is not necessarily embedded into practice.
“This is reflected in the recurrent themes identified in this report, including fetal monitoring interpretation, women reporting reduced fetal movements and subsequent care, documentation, and communication issues.” The report found a consistent failure to follow local or national maternity guidelines across all parts of the service, through pregnancy to aftercare for mother and baby, which the trust says it has now corrected and updated.
This includes the trust saying it was compliant with a national “fresh eyes” policy to check the baby’s heart rate every hour during labour, when it was actually only checking every two hours. It says the most common theme in the pregnancy stage (antenatal) was the management of care for women who reported reduced fetal movement with shortfalls in the lack of risk assessments, referrals for ultrasound scans, infrequently offering inductions of labour or offering information on inductions, and providing information in additional languages.
Communication through the maternity process and the monitoring of CTGs during labour, and being documented, were also consistent issues, the report found, which have also been found in other reviews relating to the trust, with the organisation rolling out a significant improvement programme. It details that there were 11 terminations of pregnancies after 20 weeks into pregnancy and 11 miscarriages after 20 weeks in which the babies showed “signs of life”, with the “woman’s experience” raising concerns due to the complete lack of procedure on who those situations should be handled.
The review found that live births following “medical terminations” is said to be a rare occurrence but that “this is not reflected in UHDB’s data”. It also said all cases in which babies who die after they were born before their 24th week of pregnancy should be investigated by a coroner – as of February 2023 advice – with the trust now working with local coroners on the issue.
Detailing concerns raised by women who were contacted after their babies died, the report writes: The availability of information in other languages; family members used for interpretation; screening not performed; birth planning advice given by junior medical staff; partogram not used; estimated fetal weights not plotted on the growth chart; symphysis fundal height not measured; lack of sensitivity/compassion (after birth); not following national guidance (growth restricted babies); incorrect risk allocation at booking; communication – lack of consultant involvement sought at relevant times (during labour).
Sarah Noble, the trust’s director of midwifery, said: “We remain deeply sorry to the families that we let down across the time of this review. We have made significant improvements to our maternity and neonatal services, and are providing safer care than we were 18 months ago, with better outcomes for mothers and babies.
“Our compliance against national maternity safety standards has improved and we have invested in more staff, training and equipment and are involving families in the changes we are making. While we have made progress, we are not complacent, and our teams remain focused on delivering safer, personalised and professional care to every family using our maternity services now and in the future.”
In a statement shared by the trust, the organisation says the review highlighted “cases where we could and should have done better, and areas where we had the opportunity to make care safer and improve the experience for families”. It says: “We remain deeply sorry to the families that we let down at that time.”
In a July trust board report referencing the review, which at that time had not been published publicly, Stephen Posey, the organisation’s chief executive, wrote: “The loss of a baby is an absolute tragedy and, in the rare circumstance it happens, we owe those families to have done everything possible to look at their care and whether anything could or should have been done differently. As a board we are determined that we will always choose to do the right thing, even when the right thing is not always easy.
“As a trust we will continue to support the families concerned, as well as our staff who are determined to deliver the safest care possible to every person and baby. We continue to focus on the pace of our improvements and changes, and while there is much further to go we are encouraged that these are having an impact on important safety measures.”
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