Baby deaths trigger health investigation

An investigation into the incidents between November 2010 and February 2011 was part of a review of women’s service which led to changes in procedures.

Last week, the Reporter told how Amy Daniels and Liam Frain lost their two-day-old son after mistakes during his delivery at the hospital in March.

A review of baby Joseph’s case found 18 problems and several missed opportunities to prevent the injuries that ultimately resulted in his death.

It highlighted problems with breaches of guidelines, interpretation of the cardiotocograph (CTG) monitoring his heart and poor recordkeeping.

But a confidential report before the Wakefield District primary care trust this week showed similar problems in the months leading to Joseph’s death.

The Mid Yorkshire Hospitals Trust, which runs Dewsbury hospital, refused our request to see the women’s services review.

But the primary care trust agenda said the cluster of seven incidents had been described as “a cause for concern”. For this reason, it was added to an external review of gynaecology, obstetrics and midwifery which the trust had already commissioned.

Mid Yorkshire’s chief nurse and patient of director experience, Tracey McErlain Burns, said: “We are never complacent about patient care. We seek to be a learning organisation and have always reported and responsibly reviewed services.

“We have developed a service improvement programme which, once approved, will be monitored regularly with reports to advisors and commissioners.”

The primary care trust agenda said that the head of midwifery had confirmed that one reason for the apparent increase in incidents could be improved use of a safety system designed to flag up potential risks and new guidance on reporting requirements.

But an analysis of the seven cases at Dewsbury hospital found three common themes. They were adherence to guidelines, documentation and interpretation of CTG.

Ms McErlain Burns said changes were being made following the review.

“Immediate action is always taken following the review of adverse incidents and we are revising policies and procedures and re-examining the way we provide training, such as cardiotocography (CTG) interpretation,” she said.

Actions taken by the hospital include printing guidelines to form part of the patient record, documentation and record keeping audits of each individual midwife, and using e-learning package to assess competency to interpret CTGs for all midwives.