Coroner brands maternity shortages as 'scandalous'

Death of baby at Milton Keynes hospital highlights critical shortage of NHS midwives
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Doubt was cast over the safety of Britain's maternity services yesterday after the death of a baby on an overstretched maternity ward was condemned by a coroner as "nothing short of scandalous".

Conditions at Milton Keynes General Hospital, where baby Ebony Comley-McCall died last May, were described as "chaotic"; the monitoring of her mother during labour was "inadequate"; and the pressures on midwives were "appalling", the deputy coroner, Thomas Osbourne, said.

The case highlights the growing pressure on maternity services, which are struggling to keep pace with a rising birth rate and an increase in complex conditions. The maternity unit at Milton Keynes, which has one of the fastest-rising birth rates in the country, was already being monitored for safety by the NHS regulator after the death of another baby in similar circumstances two years previously.

A national inquiry into England's maternity services involving all 150 maternity units, published in July last year, revealed a critical shortage of midwives, obstetricians absent from wards, a lack of beds and poor continuity of care. That followed separate investigations at three trusts where mothers and babies died.

Yesterday's inquest heard that Ebony was born at full term by emergency caesarean but only had a faint heart beat and died just over half an hour later. Her death could have been avoided if she had had been delivered sooner, the inquest was told. But a shortage of staff meant the urgency of her case was not recognised until too late.

Recording a narrative verdict on Ebony's death yesterday, Mr Osbourne said: "The situation where mothers are left unattended during labour and other mothers are unable to get an epidural is nothing short of scandalous. If this situation is allowed to continue, the lives of babies and mothers who intend to have their babies at Milton Keynes Hospital will continue to be at risk."

Ebony's death had close parallels with that of Romy Feast, who died in the same unit in June 2007 after an emergency caesarean. That death, the inquest into which was also conducted by Mr Osbourne, led to an investigation by the Healthcare Commission, which reported in December 2008. It criticised the lack of midwives and shortage of beds and said these shortcomings were posing "a risk to the safe delivery of maternity services."

The hospital was ordered to improve its performance and a follow-up inspection was conducted in September, four months after Ebony died; the report for this is still awaited.

Yesterday Mr Osbourne said that the number of beds in the unit had remained at 30, despite recommendations that it should be increased to 47.

He said he planned to write to the Health Secretary, Andy Burnham, about the situation and suggest that a task force is put in place.

"Anyone who has listened to the evidence cannot help but be appalled by the pressures that are placed on midwives," he said.

The inquest heard that between January 2007 and October 2009, 2,114 incidents were reported on the labour or maternity wards and that, of those, more than one in four related to staff shortages.

The Care Quality Commission said it believed care at the hospital had improved "in some areas" since December 2008, but that "faster improvements" were required.

Amanda Sherlock, deputy director of frontline operations, said it would review progress made by the trust against 12 recommendations published by the CQC's predecessor, the Healthcare Commission, last December: "The trust must respond quickly on all of the recommendations. It must get its procedures right every day, for every mother and baby."

Progress would be "monitored closely" and further action taken "if necessary," she said.

Milton Keynes Hospital Trust yesterday apologised to the McCall family for the distress and grief caused. Tony Halton, director of nursing, said: "I would like to reassure mothers and families that the delivery of safe, quality care is the Trust's key priority. We have already made changes to the way we work to further improve the safety of our services."

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