Safety alert at Wigan Infirmary maternity services
Two of the 2017 alerts at the Wigan Lane-based department are said to revolve around the monitoring of babies’ heartbeats during pregnancies, according to NHS papers.
Clinical commissioners have confirmed that they were planning to undertake an unannounced inspection of the maternity unit at Wigan Infirmary in January.
The revelation comes after the inquest of Rueben Monks, where Bolton assistant coroner John Pollard ruled that neglect had contributed to the baby’s November 2011 death, due to delays in “emergency delivering”.
And the Care Quality Commission recently gave the rating of “requires improvement” to the maternity services, with concerns including staffing levels, safety systems and infection control guidance not being followed.
NHS chiefs say the findings of the latest review were set to be shared with a meeting of NHS Wigan Borough Clinical Commissioning Group’s (CCG) clinical governance committee this month.
A CCG report disclosed that two of the three “serious incident” complaints concerned CTG monitoring for babies.
CTG is short for cardiotocography and refers to the recording of foetal heartbeats and uterine contractions during pregnancy, which is performed using an electronic foetal monitor, or EFM.
Before the visit took place, Julie Southworth, the CCG’s executive director for quality, said in the same report: “The visit will cover staffing levels and CTG monitoring systems and processes.”
She also confirmed that Wrightington, Wigan and Leigh NHS Foundation Trust, which runs the unit, had undertaken a review of all maternity service complaints from the start of January 2016 to the end of October 2017, to run alongside an internal staffing review.
Clinical commissioners have not disclosed the exact reasons behind the third serious incident complaint - though it is understood to revolve around failings involving the care of a mother, rather than her baby.
Another incident in the last quarter, a so-called “never event”, where a guide wire was found to have been left inside a baby at the infirmary, is also said to be under investigation by the CCG.
A WWL spokesman said: “In 2017, three serious incidents were reported by maternity services at Wrightington, Wigan and Leigh NHS Foundation Trust’s Royal Albert Edward Infirmary. All incidents underwent internal investigations and two, in accordance with national guidance, had additional external reviews.
“Investigation findings were shared with all families involved and action plans developed to be monitored within the trust.
“The maternity service received an unannounced CCG inspection on January 19 in order to determine the experiences and views of mothers, relatives and staff and to seek assurance that the trust was providing safe, clinically effective care in line with quality and safety standards.
“The visit received positive feedback with a number of areas of good and notable practice observed which included:
Midwifery staffing was at full establishment at the time of the visit with appropriate skill mix and experience
Good levels of support from colleagues and managers
Up-to-date training in relation to CTG monitoring and interpretation with clear escalation processes if any concerns regarding fetal monitoring were identified
Sharing of learning from incidents was evident
High levels of patient satisfaction
Mothers were involved in decisions regarding their care and treatment
Robust safeguarding procedures
The emergency response station was highlighted as an example of good practice on delivery suite.
“The inspection detailed some recommendations for consideration in order to improve the maternity service and an action plan to address the highlighted issues has been developed.
“A review of maternity incidents and complaints from January 2016 to October 2017 was undertaken that included the number and themes of incidents and complaints reported within this time period.
“This report was included as an appendix to the CCG inspection report. Maternity staffing is continually monitored both at a local and trust level with several successful recruitments of midwifery staff as vacancies have arisen.
“The investigation report relating to the guidewire has been received by the CCG for their consideration.”