A report has highlighted delays in reviews carried out following baby deaths at a maternity hospital – with inspectors finding these had not been completed 18 months after such an “adverse event”.
Watchdog Healthcare Improvement Scotland (HIS) said that such delays can “impact significantly on the mental health and grieving journey of the family involved” as well as hold up any improvements to services made in the aftermath.
Inspectors raised the issue in a report following an unannounced inspection of maternity services at Borders General Hospital in Melrose.
NHS Borders has a system in place for a standardised review of all stillbirth and neonatal deaths, with the “primary purpose” of such reviews said to be to provide bereaved parents with “clear answers” about whether the care they received was safe and appropriate, and if different care could have resulted in a different outcome for them.
This delay can impact significantly on the mental health and grieving journey of the family involved and delays systematic learning and improvement within the service
While the report made clear that all adverse incidents should be reviewed, with a significant adverse events review (SAER) carried out for the most serious cases, it said that inspectors “observed there are often delays in both commissioning and completion of reviews when adverse events occurred”.
While HIS states that SAERs should be commissioned within 10 working days of the incident, the inspectors found the time frame for commissioning such a review in NHS Borders ranged from one month to five months.
Adding that there were four SAERs currently in progress in the NHS Borders maternity service, the HIS report said that all of these “demonstrated delays to both commissioning and completing reviews”.
The report went on to state that SAERs “were seen to be still in progress up to 18 months following a significant adverse event”.
It added: “This delay can impact significantly on the mental health and grieving journey of the family involved and delays systematic learning and improvement within the service.”
Senior managers at the hospital “acknowledged the current delays” with SAERs, with inspectors being told that the small size of the obstetrics team at the hospital meant it would be “beneficial to obtain external, independent expertise” – with the report adding that this could “result in significant delays to the process”.
During our inspection we observed calm, person-centred care and staff working together to maintain good communication and provide compassionate, responsive and respectful care
This area was one of 10 where requirements for change were identified by inspectors – with another one concerning a shower room on the main corridor of the labour ward which “frequently became excessively warm”, with the report adding that “there had been instances where patients had fainted”.
While senior managers said the issue had been raised with the health board, they reported that “no funding was available to upgrade these facilities at this time”.
Inspectors also told how they saw staff at the hospital providing “compassionate, responsive and respectful care”.
HIS chief inspector Donna Maclean said: “During our inspection we observed calm, person-centred care and staff working together to maintain good communication and provide compassionate, responsive and respectful care.
“The maternity unit was calm, tidy, clean and maintained to a high standard. Women we spoke with were complimentary of the care received and would recommend maternity services within Borders General Hospital to family and friends.
“A positive, supportive working culture was evident with staff describing NHS Borders as a good place to work and feeling confident to escalate concerns.”
Sarah Horan, executive director of nursing, midwifery and allied health professionals at NHS Borders, said: “We are pleased that this report recognises the compassionate, person-centred care our staff provide every day, and the positive culture within our maternity services.
“That culture is fundamental to delivering safe, high-quality care and supporting people and families at such an important time in their lives.
“This report also reflects our ongoing commitment to delivering the best possible care for the people of the Borders and aligns closely with our clinical strategy, particularly our focus on helping people to start well from birth through safe, effective and person-centred maternity care.
“We value the opportunity to review and improve our performance so that we can continue delivering high quality care to our patients. I would like to thank the Iispectors for their report. It helps us reflect, learn and continue improving the care we provide.
“I would also like to thank all staff involved for their professionalism, dedication and the care they provide to women and families every day.”