Mother died after ‘organisational issue’ at controversial maternity unit

Parents campaigning for improvements at a maternity unit considered potentially unsafe have resumed their call for a public inquiry after the release of further damaging documents that refer to a “maternal death” due to an “organisational issue”.

Healthcare Inspectorate Wales concluded last September that the safety and wellbeing of mothers and babies could not be guaranteed at the unit in Swansea’s Singleton Hospital.

Now documents disclosed following a freedom of information request have intensified parents’ concerns. One, written in note form, states: “Organisational structure – no ITU [intensive therapy unit], women need to transfer to Morrison. 1 maternal death due to organisational issue – current HDU [high dependency unit] area is used as a stock room; the want by staff is to have acute staff trained in enhanced care and a structured pathway/team for women who require level 2+3 care

“Tunnel vision working – main concern is critical staffing no time for anything else. Family centred / individualised care – did not see service led by what women + families want only what the service is currently capable of ie stop to homebirth service and birth centre due to staffing, no current QI [quality improvement] projects or focus due to time + staffing issues, living day to day to measure risk unless an adverse event occurred.

“TC [transitional care] area 6 beds – not adequately staffed – staff pulled from ward to LW [link work] acuity staff feeling demoralised but also TC at end of ward women could feel isolated as no staff base + staff based at main ward area. No clear staff plan for the area + risk of out of sight out of mind. Excellent facilities to be utilised with a structured TC model needed.

“Triage – no clear process – have a reception area, the receptionist answers the phone and asks the questions and fills in the form?”

Brain injury

Rob Channon, whose son Gethin, now four, suffered a catastrophic brain injury because of negligence in the unit and who is a spokesman for the parents’ group, said: “IIt really speaks for itself, but here is written evidence from an NHS Wales body that a mother died because the ITU in the maternity department is being used as a stock room. The rest of the content in the cell is also incredibly damning. This wasn’t even referenced in the Health Inspectorate Wales report as far as we are aware.

“The same spreadsheet also suggests the Health Board ignored issues around the lack of staffing so they escalated it to the Welsh Government.

“And we have a spreadsheet which shows this in relation to junior staff: ‘Hierarchical effects undermine the efforts of staff to maintain and continue developing a psychologically safe environment. This is felt most strongly amongst the medical staff, within their structure. There appears to persist a strong ethos of ‘we stick together’ and one doctor will not change another’s’ plan, even if the plan is not considered the best course of action. Junior registrars are often in a difficult position, and positive outcomes will often rely on their ability to negotiate.’

“Comments in a spreadsheet are absolutely incredible: ‘URGENT: There is a need to develop a mechanism for dissemination of learning to all staff, in real time, in all areas. Our ability to disseminate learning or updates is very limited, despite repeated efforts to improve, and requires an innovative approach.

“Our inability to effectively communicate limits the ability of governance systems to be effective, specialist midwives to engage and management to have open communication with staff. To work towards exemplary evidence and experience gathered suggests that until our Health Board can address this any effort to improve is likely to fail.’

“They note this ‘urgent’ issue as well: ‘The evidence describes a significant amount of waste within the system, which impacts on the ability of all levels of staff to be able to work to role. There is unnecessary transportation, unnecessary motion, waiting, plugging gaps, staff needing to cover administrative tasks disabling them from focussing on essential improvement activities.

“There are a significant number of examples which describe an imprudent approach to healthcare, particularly in terms of human resource. For example, Band 7 ward managers spending majority of time on roster management for the unit and not on ward level work. This also impacts on staff wellbeing, feeling valued in work, and women’s experience. Staff describe a sense of helplessness where they are unable, due to existing workload (that is inefficient) to have autonomy over their work and work towards improving processes.’

“It goes on, with even more in more spreadsheets – this is just the tip of the iceberg. It all clearly shows the issues go way beyond maternity. This is an organisation in trouble, incapable of learning from incidents and keeping patients safe.”

‘Serious safety issues’

Mr Channon concluded: “This material raises some questions / points from us. It is pretty clear that a lot of people in the Welsh NHS knew there were / are serious safety issues in Singleton maternity. Why did no one speak out?

“How is the unit even safe to be open when they have no ability to care for women who become critically ill in childbirth? It should be closed until this is sorted, otherwise it is Russian roulette.

“The Swansea maternity review is fatally flawed. The very executive leadership who turned the ITU into a stockroom have appointed all the experts and Chair. It is like Harold Shipman reviewing a GP death. A public inquiry is needed to deal with this maternity scandal.”

Swansea Bay University Health Board has commissioned barrister Margaret Bowron KC to undertake an independent review aimed at determining what has gone wrong at the unit, but the parents’ group has expressed no confidence in her, saying she has refused to engage with them properly.