THE Healthcare Commission has today published what it says is a "stark picture" of the circumstances surrounding the deaths of ten women who gave birth at Northwick Park Hospital.

The results of the commission's investigation into the deaths criticises the quality of care given by the North West London Hospitals Trust in nine of the ten cases.

The HCC said its findings prompted the inspectorate to renew its call for NHS trusts to check that they have robust systems for monitoring the safety of maternity units.

The report describes what happened to each of the women, all of whom died during pregnancy or within 42 days of giving birth between April 2002 and April 2005 - significantly higher than the national average.

Common factors between deaths

The commission said: "This report, which aimed to identify if there were common factors between the deaths, paints a stark picture of what can happen when a maternity unit has inadequate systems to protect the women it cares for."

The reports said that common factors included:

  • Insufficient input from a consultant or senior midwife (in five cases), with difficult decisions often left to junior staff.
  • Failure in a number of cases to recognise and respond quickly where a woman's condition changed unexpectedly.
  • Inadequate resources to deal with high-risk cases: too few consultant obstetricians and midwives; not enough dedicated theatre staff; a reliance on agency and locum staff without adequate managerial or professional support,and a lack of a dedicated high dependency unit.
  • A culture that led to poor working practices and resulted in poor quality of care.
  • Failure to learn lessons: the trust took action following the deaths, but the working environment was such that mistakes were repeated.
  • Failure by the trust's board to appreciate the seriousness of the situation: the board was aware of the high number of deaths, and should have acted sooner to rectify problems.

The husband of one of the ten women who died after giving birth has spoken of his shock and anger at the report.

Premalatha Jeevagan, 27, was the eighth mother to die over a three-year period.

A series of blunders meant she was checked only once by a consultant obstetrician in the week she spent on the ante-natal ward.

She gave birth to her first baby, a girl whom she would never meet, by caesarean.

The report found that Premalatha, referred to as "woman H", had been sutured incorrectly and an inquest concluded "the gravity of her worsening condition with increasing blood loss was not recognised".

It also said there had been a delay in providing treatment.

'Why did they wait for someone to die?'

Preemalatha's husband, Selvaratnam, 35, of Drew Gardens, Greenford, said he was putting his life back together after the loss of a wife he described as "happy and excited at being a new mum".

"The report was shocking," he said.

"I know my wife was number eight to die, and have always thought why no one acted before to stop this happening.

"If they had acted quickly it would not have happened. Why did they wait for someone to die?

"The hospital had locum registrars and midwives from agencies, it was more like a factory than a hospital. The staff didn't talk to each other or listen to patients."

Selvaratnam has suffered depression since his wife's death, and coping with being a single dad to two-year-old Lathikah added to the stress.

He had to send his daughter to be looked after by her grandmother. Remembering the hours before Premalatha's death he said: "After the caesarean they brought her back to the ward.

"She wasn't looked after by any staff at all. My sister-in-law came to look at her and noticed her blood pressure was dropping.

"After four hours there was no one around to help her. She needed O-positive blood but it took so long I'm not convinced the blood bank had it.

"The ward was quite busy but that is not a good excuse."

The couple were married in Sri Lanka and had only three years together.

Selvaratnam has taken the NW London NHS Hospitals Trust, which runs Northwick Park, to court for clinical negligence, for which they accepted liability.

'Sad and tragic series of events'

Marcia Fry, the commission's head of operational development, said: "This was a sad and tragic series of events. We hope this report at least gives some answers to the families involved.

"At the time of the deaths, the working practices at the trust were unacceptable.

"However, under special measures the trust has got its maternity services on the road to recovery.

"We will continue to work with them to ensure that they continue to progress and that everything possible is done to stop this happening again.

"We expect trusts across the country to read this report and learn the lessons. Most women in this country give birth safely, but there are risks and the NHS must ensure it does all it can to reduce them.

"There can be no excuse for failing to learn the lessons from tragedies of this kind."

Last year, commission chairman Sir Ian Kennedy said the overall root cause of poor performance is often weak managerial or clinical leadership which can leave problems unidentified or unresolved.

The commission said it was stepping up its assessments of maternity services and planning a major survey of women's experience of maternity care, as well as a national review of maternity units.