A hospital has been ordered to carry out urgent improvements to its maternity unit after a whistleblower voiced fears about patient safety.
The Care Quality Commission (CQC) rated the unit at Basildon University Hospital as inadequate with “failings” found in six serious cases.
The CQC said lessons were not learnt from an inspection following the death of mother Gabriela Pintilie last year.
The hospital said it was “focused” on improving.
The CQC previously carried out an inspection of the department the month Ms Pintilie died and said the unit, which had once been rated outstanding, required improvement.
Inspectors returned for the surprise “focused” inspection after being contacted by an anonymous whistleblower.
The report found six babies were born in a poor condition and then transferred for cooling therapy, which can be offered for newborn babies with brain injury caused by oxygen shortage during birth.
During their visit, inspectors found:
- High-risk women giving birth in a low-risk area
- Not enough staff with the right skills and experience
- “Dysfunctional” working between midwives, doctors and consultants, which had an impact on the “increased number of safety incidents reported”
- Concerns over foetal heart monitoring
- Women being referred to by room numbers instead of their names
- A “lack of response by consultants to emergencies” resulting in delays
The CQC also referred to issues relating to the death of Ms Pintilie, who was not named in the report, and said five serious incidents “identified the same failings of care”.
“This demonstrated there had been a lack of learning from previous incidents and actions put in place were not embedded.”
Professor Ted Baker, CQC chief inspector of hospitals, said: “We have issued a warning notice requiring the trust to make urgent improvements to ensure mothers and babies are safe.”
‘Complete system failure’
Solicitor and former nurse Stephanie Prior represents Ms Pintilie’s family and said “nothing seems to change” and a robust system needed to be put in place.
“You would have thought following my client’s death that changes would have been made, but you’ve got a whistleblower in May 2020 raising safety concerns… again,” she said.
“In my client’s case… he is now left with a one-and-a-half-year-old daughter and a 16-year-old son he’s bringing up on his own.
“There is a complete system failure and there needs to be a complete overhaul of the unit to make sure it’s safe because service leaders do not have the skills to run the unit properly.”
Ms Panniker, chief executive of Mid and South Essex NHS Foundation Trust which runs the hospital, said the serious cases were being investigated independently, £1.8m had been invested in staffing and a new clinical director was in post.
Nine midwives and two consultants had already started working and 20 more midwives would join in the autumn.
She also said its poor workplace culture was “unacceptable” and would not be tolerated.
“We’ve been really focused in the last few months in making the improvements that mean women can be confident to come and have their babies in the maternity department at Basildon and be very safe in the process,” she said.
‘There’s no communication between anyone’
A woman, whose son died shortly after he was born in January after 22 weeks of pregnancy, has been critical of the care she received at Basildon.
Lauren Beattie said she was in the hospital for three weeks before his birth.
“Nearly every day I was having doctors come in encouraging me that I needed to terminate the pregnancy, even though there was nothing wrong with him,” she said.
“We ended up getting the midwife to write down ‘Do not offer [advice to terminate] any more’.
“Every time I’ve had to go up the hospital I’ve had to explain the whole situation from beginning to end to everyone – there’s no communication between anyone.
“With my most recent miscarriage [when she was pregnant again after her son died] I had four scans – one of which I did have a midwife come in for support which was lovely – but I had scans where I was all on my own to receive bad news. There are situations where people need support.”
‘Not a good report’
Lynsey McCarthy-Calvert, chair of the independent Mid and South Essex Maternity Voices Partnership which gathers feedback from patients, said she felt managers were “committed to turning” the unit around.
“It hasn’t stood out from the feedback that Basildon has been a particular concern recently,” she said.
“[But] it’s not a good report and it will be a concern to the women and families using maternity services there.
“I would say… your midwifery care will still be of a very high standard and every midwife you see will be committed to the safety of yourself and your baby.”
She said the hospital was implementing a new care model where women would be looked after by the same people during pregnancy and labour, which was known to improve “outcomes for safety and wellbeing”.