Basic failures and clinical negligence have resulted in a series of disgraceful conditions, including the death of a 22 week old baby at Pennine Acute NHS Trust, according to an internal review.
A review into the Pennine Acute Hospital NHS Trust, which operates the North Manchester General and Royal Oldham hospitals, revealed long-term failures that had caused “significant harm to women” and medical negligence on maternity wards that resulted in “high levels of harm for babies in particular”.
Among the disturbing findings of the report was the tragic discovery of a premature baby, born 22 weeks and six days into pregnancy, left to die alone in a sluice room. She had been born just before the legal age of viability, meaning she could not be resuscitated, but staff were unable to find a “quiet place” for the mother to nurse her as she died.
It is vital that all Trusts undertake careful reviews of all adverse events and their root cause, sharing their findings, to ensure action is taken so that they are not repeated.
Other instances included a mother who died from a "catastrophic haemorrhage" after staff ignored the symptoms of hypoxia, a condition caused by lack of oxygen. She was instead reported as having mental health issues.
"Worrying repetitive themes" were revealed in the review, concerning the Trust’s maternity department, including reporting failures by medical staff and neglecting to monitor basic vital signs. Another avoidable tragedy included a baby who died because antenatal staff had failed to identify the mother's rare blood type.
Several deaths were linked to staff shortages.
Regrettably, the incidents described in this report are mirrored in the cases we deal with every day. It is vital that all Trusts undertake careful reviews of all adverse events and their root cause, sharing their findings, to ensure action is taken so that they are not repeated.
The repeated mistakes made at Pennine Acute NHS Trust and the lack of candour displayed towards its patients suggests that the Trust is not receptive to learning from its mistakes; as long as this remains the case, patients will be exposed to a risk of harm in circumstances when they are at their most vulnerable.
Improvements are being made to see that patients receive “reliable, high-quality care” across all services at the Pennine Acute Hospital NHS Trust.
Publication of the report followed an application under the Freedom of Information Act, after resistance from the Trust. Professor Matthew Makin, the Trust's medical director, said: "We have fully reviewed our risk and governance arrangements including learning from incidents and complaints, and are making progress in improving the way we listen and involve our staff to address the long standing problems and challenges facing our teams.”
Lindsay Holt is a principal lawyer specialising in clinical negligence and healthcare law at Slater and Gordon Lawyers in Manchester.
The clinical negligence solicitors at Slater and Gordon specialise in claims against the NHS, GPs, private doctors and hospitals arising out of negligent medical treatment and acts on behalf of injured victims.
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