‘Poor decisions and lack of compassion’ reported at NHS trust

A secret medical review showed mothers and babies died at an NHS trust in the Manchester area where clinical errors, bad staff attitudes and chronic shortages were commonplace.

The review, carried out by new maternity director Deborah Carter at Pennine Acute Hospital NHS trust which operates North Manchester General and the Royal Oldham hospitals, outlines a string of avoidable deaths and long-term injuries caused by failures over many years.

The report details how a premature baby was left to die alone in a sluice room rather than its mother’s arms, another woman who died of a catastrophic haemorrhage after her symptoms were put down to mental illness and a baby who died because staff failed to identify its mother’s rare blood type.

Long-term failures led to “high levels of harm for babies in particular” and repeated warnings over years had not led to improvements.

The internal review only came to light following a freedom of information request by the Manchester Evening News. The paper said the trust tried to suppress the report and even claimed it did not exist.

On Wednesday night the trust said more staff had been taken on and progress was being made to improve care.

The report identifies “clear evidence of poor decision-making which has resulted in significant harm to women” and “real issues” on maternity wards resulting in “high levels of harm for babies in particular, which has significant life-long impact”.

Staff shortages are linked to a series of deaths, including one baby who died because antenatal staff had failed to spot its mother’s blood type. But bad attitudes and a lack of compassion among staff were also cited.

In one case a mother died from a “catastrophic haemorrhage” after staff ignored the symptoms of hypoxia, a condition caused by lack of oxygen, while medics believed the woman had mental health issues.

Another incident involved the birth of a 22-week-old baby. The report states: “When the baby was born alive and went on to live for almost another two hours, the staff members involved in the care did not find a quiet place to sit with her to nurse her as she died, but instead placed her in a moses basket and left her in the sluice room to die alone.”

The report cites “worrying repetitive themes” across the department, including failures to monitor basic vital signs, poor documentation, lab results left unchecked, critical information left off patient records, a “rigid mindset” among staff who tended to view patients’ conditions as “uncomplicated”, repeated breaches of safety procedures and little performance monitoring of the high numbers of agency staff on the trust’s books.

The trust received more legal claims and paid out more in damages than any other between 2010 and 2015, nearly half the claims relating to mothers and babies – payouts that totalled more than £25m.

Prof Matthew Makin, medical director at Pennine, said: “The priority is for all of the trust’s services to meet the high standards that patients expect and deserve. We are steadily making the necessary improvements so that patients can receive reliable, high quality care across all of our services.

“In addition to the appointment of a new head of midwifery, 31 new midwives started … across our two maternity units at north Manchester and Oldham last month.

“In addition to 58 new midwives joining us since April, the new management team is being supported by Central Manchester NHS foundation trust, who are providing supplementary clinical leadership support in order to stabilise and strengthen services on the north Manchester site.

“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 longstanding problems and challenges facing our teams.”