A new safety review of the maternity units within University Hospitals of Derby and Burton NHS Foundation Trust has highlighted staffing gaps, ineffective communication and widespread confusion among maternity staff around how to escalate emergencies.

JMW is  acting for a family whose newborn son, Baby Zac, very sadly passed away while under the care of Derby and Burton NHS Foundation Trust in late 2022. We are alarmed by the similarities between a number of issues identified in the report and those that arise in the circumstances surrounding our client’s baby’s death which occurred some months after the period investigated.   

Zac’s family are concerned that information they would have wanted to know was not shared with them during the ante-natal period and that when after birth Zac presented with a number of symptoms that they were concerned about, they were not acted on despite his parents flagging them to midwives. Then, when his condition rapidly deteriorated, it seems from what they have learnt so far that emergency calls were directed to the wrong team and thereby not responded to quickly enough. By the time doctors reached him, he was in severe distress and treatment was started too late.

Nicola Wainwright, partner and head of clinical negligence London at JMW Solicitors, said:

“Baby Zac’s family are understandably distraught and seriously concerned about what happened to their baby, and these concerns are only heightened by this report which refers to problems in the maternity service at Royal Derby Hospital that they experienced too, particularly regarding poor communication between staff and a lack of knowledge as to how to escalate emergencies.

 “They hope that some of their concerns about the exact circumstances of Zac’s death will be explored at an inquest later this year, but in the meantime they worry that other families will also suffer heartbreak like they have, unless the trust acts quickly to improve its maternity services.”

The independent report, which has been completed by the Healthcare Safety Investigation Branch (HSIB), was published last  week following three maternity deaths and four maternal collapses at the trust’s hospitals between January 2021 and May 2022. Following interviews with midwives, doctors, and the families of those affected, the report details how the care of the seven women and their babies has been impacted upon by a number of issues within the trust, namely:

• Inconsistent guidelines between the hospitals’ maternity units following their merger in 2018
• Significant gaps in midwifery staffing, which meant that one midwife could typically be responsible for the care of up to nine women and their babies
• Trouble with communication, both amongst staff -  as midwives felt unable to approach consultants for fear of bullying treatment -  and between patients and staff, with staff  unwilling to involve patients in decisions about their care
• Lack of whole picture thinking as many teams worked in siloes
• Confusion in emergency situations as the national guideline of having one emergency escalation number to use across-the-board was not followed

HSIB make a number of recommendations to the trust such as clarifying processes to ensure safe and timely care, adhering to national guidance on emergency calls, and ensuring that families are involved in incident reviews wherever possible.

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