Damning report into failures at Northwick Park hospital

Following an earlier Review of Maternity Services provided by North West London Hospitals NHS Trust, the Healthcare Commission has now published the results of its Investigation into10 maternal deaths at, or following delivery at, Northwick Park Hospital, North West London Hospitals NHS Trust, between April 2002 and April 2005.

The families represented by Leigh Day & Co welcome the Healthcare Commission’s investigation, but are deeply saddened to read of the extent of the failings that existed at Northwick Park. The Report has identified deficiencies in the care and treatment of all but one of the 10 women and criticises the Trust for maintaining “that there were no common factors between the deaths.”

Ana Maria Denzo was the tenth woman to die at Northwick Park and it is clear from the Healthcare Commission report that the hospital had repeatedly failed to learn lessons from the 9 deaths prior to that of Ana Maria. Arnulfo Denzo said today:
“I feel angry that despite Ana Maria being a nurse and working for the Trust that she died in this terrible way.  Justice needs to be done.  Ana Maria was a perfectly healthy young woman who had never been into a hospital before except to work.  Whilst it is too late for our child and our family I can only hope that Northwick Park and every other maternity unit will actually take on board the recommendations of the Healthcare Commission and learn lessons from Ana Maria’s and the other women’s deaths. I hope that no other women nor family will have to suffer this fate.”

Significant failings

The report highlights in stark detail the Trust's failings in two significant areas. Firstly, despite dealing with the most high risk of pregnancies, the maternity ward was over-reliant on junior staff,and the mechanisms in place for junior staff to discuss concerns were woefully inadequate. Secondly and equally concerning are the Commission’s findings that the Trust repeatedly failed to learn from the women’s deaths. It becomes clear from the report that the way in which the Trust reviewed the deaths was entirely unsatisfactory. Indeed from July 2003 the information about these incidents was not presented to the Trust board. The Commission states:
“It is unclear who decided not to include maternity services information, or the reason for this decision”
it is further stated that:
“The external review of the first three maternal deaths was reported to the board, but there is no further written reference to the maternal deaths until following the review in February 2004. The eighth and 10th maternal deaths were reported to the board”

Why were these deaths not reported as they ought to have been?  There appears to have been an unwillingness to acknowledge the extent of the deficiencies that existed within the maternity services. The effect of failing to adequately report the circumstances of the deaths and so to learn from the individual and systemic failings, sadly leads to the conclusion that women have lost their lives when they ought not to have done.

It is accepted that improvements have arisen as a consequence of the Healthcare Commission's report.  Mary Wells, current chief executive of the NW London Hospitals NHS Trust, said today:
"Lessons have been learnt and we continue to do all we can to avoid tragedies of this nature happening again".  Clearly this is welcomed by our clients but why were lessons not being learnt when women were dying?  Questions remain unaswered.

• Why were the most high risk pregnancies being handled by junior staff without the input and supervision of consultants?
• Why were pregnant women placed in the hands of a Trust who were ill equipped to deliver their children safely?
• Why did a 10th woman have to die despite the Healthcare Commission's previous concerns?

Following each death the trust undertook some form of investigation and in some cases external investigations were carried out.  However, the internal investigations were narrowly focused on care provided by the obstetricians rather than taking a wider approach and considering the context in which the deaths occurred.

Key findings

Unsafe maternity services

• The maternity service was offering care to women whose pregnancies represented a high risk, but did not have the necessary systems or staff with the appropriate skills in place to manage such cases.
• There was a lack of input from consultants at crucial times, and there was an over-reliance on junior staff to manage complex and difficult cases with little guidance or support.
• Consultant obstetricians did not routinely carry out ward rounds when they were responsible for overseeing care in the labour ward and the teamwork between midwives and obstetricians was not as effective as it should have been.  Therefore, there was no adequate mechanism in place for staff to discuss concerns that they may have had about the women.
• There was an excessive reliance on the use of locum and agency staff, who did not always receive the necessary guidance or support.
• Deficiencies in the management structures also contributed to the poor quality of care the women received, for example midwives were expected to manage a busy delivery suite that was reliant on agency and locum staff, with at times, little professional or managerial support.
• In the majority of cases the women attended their hospital and GP antenatal appointments and sought help when they felt unwell.  Yet despite this, in a number of cases, clinical staff failed to recognise and respond to the severity of the condition of the women, thereby reducing the chances of survival of the women.  In some of the cases there were minor deficiencies in care which, in isolation, may not have had such a dramatic impact, but when occurring together had serious consequences for the health of the women concerned.

Failure to learn lessons

• The actions that the Trust took were not comprehensive and the prevailing culture in the maternity services during this period did not facilitate learning from adverse incidents.
• The investigations had a strong medico-legal focus.
• The result of the way in which the Trust carried out internal investigations was that learning from the deaths was not as effective as it should have been.
• The Trust maintained that there were no common factors between the deaths yet the health care commission highlighted a number including lack of input from consultants and poor clinical judgement.

Conclusion

The Healthcare Commission conclusions speak for themselves. "Maternity services at Northwick Park hospital were in a state of upheaval - it was a service fraught with tensions and frustrations.  There was a lack of leadership, poor communication between staff, ineffective teamwork and, perhaps, most significantly, a lack of awareness of how this was affecting the safety of patients and the quality of care that was being provided.  Despite the good intentions of the staff, who were working in very difficult conditions, their practice and ultimately the care that they provided were compromised by the environment and the culture in which they were working.  It was an environment that allowed the quality of care to fall below properly professional standards and poor working practices to flourish".

Leigh Day & Co represent the families of two of the women who died at Northwick Park Hospital during the period covered by this investigation. If you have been affected by any of the issues mentioned in this article please contact Sarah Campbell or Ian Christian on 020 7650 1200.

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