Managers at Nottingham’s crisis-hit maternity units are still investigating 61 Serious Incidents. Twelve of these incidents involve maternal deaths, neonatal deaths, stillbirths, or severe brain injury in babies.
Some of the incidents date back years. Serious Incidents are unexpected or unintended events that could cause NHS patients harm.
But it's understood that Nottingham University Hospitals Hospitals Trust (NUH) has not directly passed on details of the backlog to a review team overseeing the city’s maternity units. Maternity services at NUH have been declared inadequate by health watchdogs.
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The Government appointed the independent review team following a campaign by bereaved families. NUH says it aims to complete Serious Incident (SI) investigations within 60 days. This target was suspended during the pandemic and has not yet been reinstated.
Some of the 61 SI investigations date back years. The oldest of the incidents happened in 2019. Another incident was in July 2021.
NUH board papers say 54 of the 61 investigations have exceeded the usual deadlines. NUH has pointed out its threshold for declaring Serious Incidents has been lowered.
But at least one board member has described the incident investigation backlog as “unacceptable”. Eight of the 61 incidents occurred when a maternity unit was closed unexpectedly and mothers had to be transferred.
During September’s board meeting, Director of Midwifery Sharon Wallis said: “We have a significant number of Serious Incidents. We have a cluster being reviewed. We have support from the regional team to try to get through the backlog.
“We need to understand where things have gone wrong and learn lessons for families. I’ve personally spoken to one of the women [involved] and apologised profusely, because it isn’t good enough.”
The trust – which runs maternity services at the Queen’s Medical Centre and Nottingham City Hospital – says it hopes to complete investigations into the remaining SIs by December 23. More than 700 families and more than 160 members of staff have contacted the independent review team, to share their experiences, since it started work last month.
During the September board meeting, non-executive director at NUH Professor John Atherton admitted the number of SI investigations was unacceptable. He said: “We apologise sincerely and we are doing everything we can to try to make things better. I also thank the staff in the trust who are working as hard as they can to put things right.
“I believe all the incidents currently outstanding should be dealt with by Christmas. It is a priority that we get that backlog down.”
Dr Keith Girling, Medical Director at Nottingham University Hospitals Trust, added: “We are sorry to those people where there has been any form of incident during their care. We acknowledge we have a backlog of cases and we are committed to ensuring that there is regular contact with families to keep them updated on the progress of the investigation.”
The NUH board will be updated on Serious Incident investigations at its next meeting, on November 24.
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