Baby death unit problems revealed

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Problems at a maternity unit where a newborn baby died because an emergency caesarean was delayed have been revealed in a new report.

The Healthcare Commission said more midwives, more beds and stronger leadership were needed at Milton Keynes General Hospital in Buckinghamshire.

Staff are under so much pressure they have no time to complete training or improve patient care, the report said.

The commission investigated the unit after the death of Romy Feast in 2007.

The baby girl died less than an hour after she was delivered at the hospital by caesarean section.

In February coroner Thomas Osbourne, sitting in Milton Keynes, said a caesarean section should have been performed urgently but was instead delayed by three hours by a series of "system and communication failures".

There has been pressure on bed occupancy, with some midwives worried that mothers and babies were being sent home too early to make way for the next delivery Nigel Ellis, Healthcare Commission

The concerns of two experienced midwives were ignored and a registrar decided to induce labour.

Drugs used increased the pressure on Romy, whose heartbeat was already abnormally high.

In the months after the baby's death a national review of maternity units by the commission rated Milton Keynes' unit 134th overall in England out of 148 trusts.

The commission has instructed Milton Keynes Hospital NHS Foundation Trust to improve its maternity unit with measures including more beds and midwives to serve the town's growing population.

The trust needs to "immediately recruit more midwives and supervisors of midwives and to strengthen its leadership by ensuring that key senior posts are not allowed to remain vacant for long periods of time".

The post of head of midwifery, vacant for two years, has only recently been filled.

Investigators concluded reports on serious incidents and errors were often poor and inconsistent.

Recommendations accepted

Maternity guidelines were found to be inconsistent and out-of-date and the report also noted that while the birth rate had risen in Milton Keynes over the past five years, the number of beds had been reduced.

The report did not raise concerns about the level of skill and dedication of staff members working in the maternity unit.

It makes 12 recommendations to the trust for improvements and will monitor progress before a formal review in 2009.

Nigel Ellis, the commission's head of investigations, said: "Overall we found the maternity staff were an enthusiastic and dedicated team who wanted to perform effectively.

"But they were under so much pressure that they had to concentrate on day-to-day issues with little spare time to attend training courses, risk meetings or clinical audit meetings, for example.

"There has been pressure on bed occupancy, with some midwives worried that mothers and babies were being sent home too early to make way for the next delivery."

Tony Halton, director of nursing at Milton Keynes Hospital, said: "We called in independent experts to review our clinical governance processes and ensure they are robust.

"We accept all of the recommendations and changes have already been made."

Dr Nicholas Hicks, chief executive of NHS Milton Keynes, said: "I very much welcome the provision of additional beds and the proposed building of a new maternity unit."