A “LONG-STANDING” and “poor” staff culture has seen Basildon Hospital’s maternity unit issued with a damning inspection report which has labelled the department inadequate.
Inspectors from the Care Quality Commission carried out an unannounced inspection at the unit after a whistleblower raised concerns over the safety of the department.
During the inspection, the inspectors found high-risk women were giving birth in the low-risk area and insufficient numbers of staff had relevant skills and experience to keep women safe.
The report, published today, also pointed to a lack of learning and leadership by the unit, even after mum Gabriela Pintilie’s tragic death in February 2019.
Inspectors said: “The service had a maternal death in February 2019.
“The issues identified from the investigation related to incorrect interpretation of cardiotocography – a way of recording the baby’s heartbeat and the contractions during pregnancy; failure to escalate risk from the midwives to medical staff; and failure to escalate risk from middle grade doctors to consultants.
“There were a further six serious incidents reported between January 2020 and April 2020. These serious incidents identified the same failings of care.
“This demonstrated a lack of learning from previous incidents and actions put in place were not embedded. We observed that incidents were not always graded correctly.
“For example, incidents from January 2020 to April 2020 included a post-partum haemorrhage with blood loss of 3,000ml, a maternal transfer to intensive therapy unit and term babies admitted to the neonatal unit were graded as no or low harm.”
Worryingly, staff as well as the unit’s senior leadership team told the inspectors about a long standing poor culture over a number of years, which had resulted in a deterioration of the safety of the service and, as a result governance and oversight for improved progress and change was not robust.
The report also states the inspectors were not assured sufficient steps had been taken to address the culture issues prior to a new interim clinical director and general manager’s appointment.
It adds: “The new senior leadership team also told us that there had been a lack of leadership oversight of the consultant body’s support for junior medical staff.
“The junior medical staff found it difficult to approach and escalate risk to some of the consultants for support as they were made to feel incompetent.”
The inspectors also found that the service did not always have enough staff to keep women safe and to provide the right care and treatment.
Inspectors added: “We were not assured that the service leaders had the skills and abilities to run the service.”
In a wide-ranging interview with Clare Panniker, chief executive at Basildon, Southend and Broomfield Hospital, she said the hospital has drafted in a new leadership team, invested £1.8million in recruiting 29 more midwives and two additional consultants, opened three more delivery beds for high risk women, and created a triage service.