Healthcare Commission reports on maternity services at Northwick Park Hospital
07/07/2005
I would like to thank you and your colleagues for the kindness shown to myself and my wife. I class myself as very fortunate to have met such kind and caring people.
Raymond, Hertfordshire
The Healthcare Commission published its report today of the investigation into maternity services at North West London NHS Trust.
The investigation revealed problems with lack of equipment, overcrowded wards, staff shortages, poor communication, lack of information and support for patients and bullying amongst staff.
In February 2004 an internal investigation was launched by the trust after the deaths of seven women who died between April 2002 and December 2003. Their attempts to tackle the problems were unsuccessful when a further two women died in May and June 2004.
The Healthcare Commission was called in and an external review was launched in August 2004. During the investigation a 10th death happened in March 2005. The Commission took immediate steps and recommended that urgent special measures were needed to ensure patient safety. The Secretary of State acted to make them operational.
Mrs Premalatha Jeevagan aged 27 was the mother who died at Northwick Park hospital (part of the North West London NHS Trust) in May 2004, after giving birth to her first child.
Following a caesarean section Mrs Jeevagan was under the care of a locum doctor, as senior obstetric medical staff were not available. Her condition began to deteriorate and in the early hours of the 18th May Mrs Jeevagan went into cardiac arrest. She was rushed to theatre where it was found that her uterus was filled with several litres of blood. Mrs Jeevagan sadly died on the operating table.
"The fact that an internal investigation was conducted in February 2004 - just three months before Mrs Jeevagan's death - has caused particular distress to the family. If action had been taken at this point Mrs Jeevagan may not have died," said the family's solicitor Louise Forsyth of Alexander Harris Solicitors.
"Many of the recommendations made by the Commission today tackle the problems that Mrs Jeevagan and her family experienced at the hospital. The recommendations are welcomed but come too late for the family. If basic measures of communication, proper training and care were in place Mrs Jeevagan's death may have been avoided. That will be very difficult for the family to come to terms with," added Louise.
Immediate recommendations made by the Commission include:
- Improvement in communication with women and their families, especially with members of minority ethnic populations served by the trust. As part of this, all staff in maternity services must attend the trust's cultural awareness training.
- Review of all equipment used in maternity services and a system in place to ensure effective maintenance.
- A full time consultant obstetrician to provide clinical leadership on the labour ward, particularly for women assessed of being at high risk of complication in their pregnancy.
- Specific training and enhancement of skills for staff caring for women after surgery in maternity services.
Notes to Editors:
- The Healthcare Commission is the independent inspection body for both the NHS and independent healthcare. For more information please visit www.healthcarecommission.org.uk
- All media enquiries should be directed to Alexander Harris' media department on 08700 77 88 77.
- A photograph of Mrs Jeevagan has been released by the family. Please contact the media management department at Alexander Harris for a copy.
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