Hospitals face inquiry after deaths of babies

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An investigation is to be launched into neonatal wards after research suggested that 15 babies died or were seriously hurt in "catastrophic'' errors in 18 hospitals over nine months.

An investigation is to be launched into neonatal wards after research suggested that 15 babies died or were seriously hurt in "catastrophic'' errors in 18 hospitals over nine months.

Sue Osborn, director of the National Patient Safety Agency (NPSA), said it was treating as a high priority the adverse incidents. The research highlighted serious shortcomings in the treatment of the newborn.

Experts from the NPSA, which is beginning its first programme of work, found that one of the highest risks in treating newborns related to mistakes in calculating drug doses.

It is also investigating mistakes in maternity care, amid concerns that chronic midwifery shortages are leading to high rates of Caesareans and complications when women give birth.

The NPSA was set up last year to identify "adverse incidents" in the NHS and order policy changes to try to reduce the number of patients who suffer from mistakes.

In a pilot study of 18 NHS trusts over nine months, more than 170 medical mistakes in neonatal services were reported to the agency. Nearly one in 10 of those was rated as "major or catastrophic", meaning they resulted in serious harm or death to babies.

The proportion of major and catastrophic errors in neonatal services was by far the highest for all clinical specialties. It was almost double the rate of the next highest, accident and emergency, where just 5.8 per cent of errors had serious consequences.

Ms Osborn said the high rate could be put down to the frail and often seriously ill condition of the babies on neonatal wards.

Professor David Field, honorary secretary of the British Association of Perinatal Medicine, said: "Miscalculations with drug doses are a common problem and it is something the Royal College of Paediatrics is also looking at.

"If the condition of a seriously ill baby suddenly deteriorates, doctors can be rushing around trying to calculate doses of powerful drugs for very small babies.

"The reason why the outcomes of such mistakes can be so catastrophic is that often the mistakes multiply the strength of the drug by a factor of ten or even a hundred, and in a tiny baby that is very serious."

Professor Field said that understaffing in neonatal wards could add to the problem, with doctors having to rush from one baby to another.

Concerns have also been raised on the lack of intensive care cots for newborn babies who are seriously ill. Babies regularly have to be transferred to other hospitals, sometimes hundreds of miles away, because of a lack of a suitable high-care cot.

Research published earlier this year found that more than half of babies who were stillborn or just after birth in England had received sub-standard care that may have contributed to their deaths.

The NPSA has also opened an investigation into maternity services, at a time when Caesarean rates have reached a record high and many women are complaining that they are left alone during labour because of midwife shortages. One in four midwife posts in some hospitals has been vacant for more than three months.

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