An independent maternity review conducted by the Health and Safety Investigation Bureau (HSIB) (an organisation created to investigate patient care), has found that the deaths of three women whilst under the care of Royal Derby Hospital, part of the University Hospitals of Derby and Burton NHS Foundation Trust, over the period January 2021 to May 2022 may have been preventable.

Four other maternal life-threatening incidents had also taken place over the same 16-month period and were included in the investigation.

The 74-page report made several findings including:

• Significant staffing gaps
• Documentation was not completed in full or was missing altogether
• Level of communication led to an unwillingness to involve women and their families in decisions about their care
• Limited evidence of follow up care once a woman had been discharged from hospital
• Communication once discharged has been ‘unbelievably poor’ and families felt ‘abandoned’ by the Trust.

Although there were no common themes that directly impacted upon the outcome of the seven women involved in the investigation, HSIB have made several safety recommendations to the Trust including following guidance in respect of declaring obstetric haemorrhages and use of the universal 2222 call for emergencies and ensuring that communication with women and their families continues into the post-natal period.

One of the women who sadly died worked at neighbouring Nottingham University Hospitals Trust and had chosen to have her baby at Royal Derby Hospital due to her concerns over the maternity care services at Nottingham.  

This is another alarming example of the extent to which maternity services are struggling in the UK.

We act for so many families who have suffered as a result of poor maternity care. This investigation  is another example of how mothers are injured as a result of poor maternity care. We encourage anyone who has been affected by care received from University Hospitals of Derby and Burton NHS Foundation Trust to make contact  with us so that we can begin to support you too.