SERIOUS failings resulted in women who were not "low risk" having their babies at Wyre Forest Birth Centre, the inquiry has ruled.

The final report says "that where complications arose during pregnancy these were not always recognised and followed up as they should have been" and "symptoms in the mother, that could have indicated significant problems, were not investigated as thoroughly as they should have been".

It adds "warning signs that all might not be well with the baby were also not acted upon appropriately".

In some cases, midwives failed to make appropriate referrals to consultants for advice about these complications and there were also occasions when referrals were made but the doctor failed to take the necessary action.

Mr Rostill said: "I think this report suggests that the protocols weren't strictly adhered to in all cases and they looked at a sample of other case notes, as well as the six deaths and there were some concerns as to which protocols were being followed in parts of 2003."

He added: "There have to be strict and adhered-to protocols and any deviation from these leads to risk and that is simply unacceptable."

The report explains the trust developed new guidelines on booking births, which should have been implemented in April, 2003, listing a range of risk factors, all of which required the mother to be referred for a consultant opinion on whether consultant-led delivery and care was available.

It says: "despite being circulated to all staff, there was evidence that midwives were unfamiliar with the new guidelines and continued to use the old numerical scoring system".

It adds: "Since the booking arrangements were a key factor in the success of the operation of the unit, the failure to comply with current guidelines was a serious issue."

It adds women using the unit had a right to choose where they had their babies and when they decided on Wyre Forest Birth Centre or home births - against advice of health care professionals - this should have followed detailed discussion and that discussion should have been recorded.

Evidence was found, however, that these guidelines were not always followed.

"In three of the six cases which resulted in perinatal death, there were risk factors in the mother's medical or obstetric history which meant that a consultant opinion was needed on whether delivery at Kidderminster was advisable under the birth centre guidelines.

"In each case the mother was appropriately referred by a midwife. However, two of these were seen by a doctor on the consultants team rather than the consultant personally".

The report also refers to concerns from the outset about the viability of the unit on financial and clinical grounds because of the low number of births.

"While the panel found no evidence of direct pressure being applied to any birth centre staff, nevertheless sufficient evidence was presented that the perception of some staff was that numbers needed to be increased and that they may have been influenced by this when making decisions about bookings," it adds.

"This may have led to women who were not low risk being booked for delivery at the unit."

Recommending doctors and midwives should record discussions with mothers and the rationale for decisions about where they wish to have their babies in handheld maternity records, it adds: "These are serious failings that resulted in women who were not low risk having their babies at the birth centre.

"It put mother and baby at unnecessary risk and may have contributed to the outcome."

Mr Rostill said: "There are some very useful points in this report and I will be pleased to be measured on their implementation."

He added the trust was putting the finishing touches to new guidelines on the care of low-risk women during labour which are based on the latest available clinical evidence and also hoped to appoint a consultant midwife and a modern matron for the birth centre to provide more midwifery expertise.

Mr Rostill said: "We now have far more rigorous monitoring of the performance of midwives and consultants.

"They are expected to keep written records of discussions with mums-to-be about their treatment and any investigations into incidents are dealt with at the highest level.

"Midwives based at the birth centre spend time at our other maternity units. All staff are expected to update their skills regularly and there is now a structured training programme offering a wide range of options."

In the recent county-wide review of services, he said considerable efforts had been made to involve women who had used the services or who may use them in the future.