At Chester Hospital, the investigation was launched following an unusually high number of baby deaths between June 2015 and June 2016, when eight babies died. The Hospital Trust contacted police because an independent review was unable to account fully for the causes behind all the deaths. The police will be asked to rule out unnatural causes.
I am sure that this investigation will bring significant distress to those affected.
In our own inquest last week into the death of baby F, reported in the Evening Standard today, the coroner listed countless missed opportunities to save F during her mother's labour and following her birth. Most of these centred on the failure to act on pathological CTGs (recordings of the baby's heart rate) that clearly indicated that the baby was in distress. These were not acted upon quickly enough by doctors and midwives caring for F and her mother. An emergency C-section should have been performed, however delays and indecision meant this did not happen.
There were also failings in respect of F's care following her delivery. Intubation was delayed and an urgently needed blood transfusion was not provided and F died.
The Coroner found that there were multiple failings in care which led to the outcome.
Along with the internal investigation into F's death, an independent review of perinatal care at West Hertfordshire Hospitals NHS Trust, which runs Watford General, was also commissioned because of concerns over four baby deaths during a twelve month period, including F's. Patient safety and serious incidents involving CTG monitoring were specifically identified.
The report highlighted problems with staffing levels and leadership in a labour ward that was extremely busy, with obstetric trainees having to prioritise between urgent cases.
The outcome is that the West Hertfordshire Trust has implemented significant changes to its working practices and procedures.
Basic care such as the correct use of CTG monitoring and the appropriate, urgent response to suspicious or pathological readings are fundamental to the safety of mothers and babies. Until every hospital in the UK undergoes adequate training and until appropriate procedures are put in place to ensure this basic care is provided to every woman and baby in every labour ward, investigations such as that at Chester and Watford General will sadly continue to be necessary.
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