FAILINGS IN STANDARD OF CARE WHICH MAY HAVE CONTRIBUTED TO DEATHS

Six unexpected deaths in newly born babies in less than three years in a "low risk" unit is clearly a matter of grave concern.

All babies were full term, ie they were not born prematurely. They were all expected to do well, otherwise they would have been transferred to the consultant-led unit at Worcester. Only one was found subsequently to have a significant congenital problem (a heart defect).

The inquiry team, therefore, looked particularly closely at these cases, taking evidence from parents as well as examining the case notes.

This revealed that there were failings in the standard of care provided, some of which were serious and may have contributed to the outcomes.

In investigating these deaths the inquiry team also uncovered evidence that highlighted more systematic weaknesses in the way mothers and babies were cared for at the birth centre. These were confirmed by examination of a further sample of case notes.

The trust's own internal monitoring systems and investigations failed to pick up all these problems.

STRUCTURES AND PROCESSES

NOT FUNCTIONING EFFECTIVELY

The trust and the birth centre had arrangements to ensure the quality and safety of clinical care in line with the national programme of clinical governance, assessment and reporting.

However, although the structures and processes were largely in place, they were not functioning effectively.

In terms of clinical outcomes, there was a lack of data with which to make meaningful statistical comparisons between the birth centre and other units.

POOR COMMUNICATION AND LIMITED ACTION TO ACQUIRE VIEWS OF MOTHERS

Women who use maternity services have a key role to play in helping to shape the care they and their babies get. The birth centre had taken some steps to get their views but evidence of positive engagement and real involvement was limited.

Information was given to women and their families both about the services available and about their own and their babies' care, but there were areas where communication needed to be improved.

GAPS AND SHORTCOMINGS IN

TRAINING OF STAFF AND A

RESISTANCE TO CHANGE

The birth centre was adequately staffed. The staff were experienced, caring and committed but there were gaps and shortcomings in training and very little evidence of a learning culture.

Relationships with the rest of the trust were poor and resistance to change was marked in some staff.

SERIOUS MANAGEMENT WEAKNESSES AND LACK OF LEADERSHIP BY TRUST

There were serious weaknesses in the management of the birth centre by the trust. These began with a failure to develop a vision for the service model and operation policies when the birth centre was established.

Lines of accountability were blurred, managerially and professionally, and there was no effective monitoring of performance. These failings were compounded by rapid changes in staff and structures within the trust and by the size of the agenda it faced which put a huge burden on staff. The result was the birth centre was, to a great extent, isolated managerially and lacked leadership from the trust.

The Primary Care Trust made little use of its role as commissioner for the maternity services for the residents of Wyre Forest to have an input into the birth centre.

RIGHT DECISION TO CLOSE CENTRE ON GROUNDS OF SAFETY AND QUALITY OF CARE

The unit was closed on September 19, 2003, following the deaths in August and a further untoward incident in early September, because of concerns about the safety and quality of care. The closure was decided upon by the chief executive of the trust on the advice of the clinical director for obstetrics and gynaecology and the heads of midwifery. On the basis of their advice and the information then available this was the right decision.

The further information which has come to light during this inquiry confirms that this was the correct action.

However, the future of the unit now needs to be decided as a matter of urgency.