Agenda item

The Chairman invited to the meeting:

·       Ms Sanders, Chief Executive, Barnet Hospital

The Chairman asked Ms Sanders to provide an update following a maternal death in February 2020 at the RFH. The Care Quality Commission (CQC) had undertaken an inspection of the Trust in October 2020 and the Report is attached with the supplementary papers.

Dr Sanders reported that the patient was given the wrong dose of a drug in February 2020. There was also a concern about her deterioration regarding doctors in escalating problems in accordance with the guidelines and the CQC had noted in its Report published in January 2021 that safeguards had been put in place across all three hospitals to prevent this incident happening again.  Dr Sanders stated that this event has caused great concern but she wished to emphasise that a comprehensive plan is in situ.

A major issue had been communication with the patient for whom English was not her first language, including printed leaflets on reduced foetal movement which should have been provided to her. A lot of work had been carried out to ensure that staff knew how to signpost patients in such cases. This was being shared across NCL.

Dr Sanders reported that the CQC had also found that staff had not been able to demonstrate to them that they had learnt from previous incidents. The Trust has since improved its communications on this and is holding staff briefings, keeping a log of who has attended.

Dr Sanders explained that the apology, which is normally included in the standard letter which is sent out following an incident, was unfortunately missing, as it had been removed in error in this case.

The CQC had also expressed concern around IT systems including an alert system that looks at women’s observations. At BH it is done electronically but the RFH had moved to paper due to concerns with its IT infrastructure. Some work has been done at the RFH to resolve this and it is hoped that the CQC will come back again this month to review the situation.

A Member asked whether there had been concerns about the RFH Maternity Unit prior to the CQC Report. Dr Sanders responded that the IT issues had been known about and efforts were being made to resolve these. However, the issue regarding translated leaflets had not been as high on the Trust’s radar as it should have been. 

The Member further commented that items had been on the Risk Register for some time and asked whether this was a concern as it was highlighted in the Report. Dr Sanders responded that a workaround had been found on the IT issue so that should have been removed from the Risk Register. Ideally, the Trust should have the option to automatically extract data from the IT system but this had not been possible so it was being done manually. 

Another Member asked whether there is a statutory requirement to supply leaflets in certain languages. Dr Sanders responded that the Trust has reviewed the population which uses its services and provides leaflets in the top ten languages. There is also a process to provide that information to speakers of other languages via the ‘Big Word’ and there is access to translation services by telephone as well as face to face which needs to be booked.

The Chairman asked whether the lady had had a birth partner who could have translated for her as this incident was prior to the Covid-19 restrictions being put in place. Ms Sanders responded that the main problem was that she had not been given a printed leaflet on foetal movement to take away with her. Also, the hospital prefer the ‘Big Word’ to be used rather than relying on relatives to be translators as they are not always conversant with medical language.

A Member noted that there had been previous occasions in relation to the Quality Account (QA) where items had been on the relevant Risk Register for several years and this had been pointed out to the Trust. It did not appear that progress was being made. The question was whether the incident had prompted the Trust to look in more detail at risks that had continued to remain on the Register and not been resolved. Ms Sander responded that the incident has prompted the Trust to scrutinise the Risk Registers and to remove items that had been resolved and should have been removed.

Ms Sanders clarified that in relation to Maternity Services this related to manual validation of the data being needed in relation to the quality dashboard. The RFH is due shortly to embark on the next phase of the Electronic Patient Record (EPR) which is already in place at BH and CFH. 

A Member stated that this issue would appear to go back to 2014 and that the risk had not fully been fixed but is being tolerated with people being asked to work around it. Ms Sanders clarified that the IT issue had no relation to the serious incident in the Maternity Unit. It related to the data that came into the quality dashboard and had been noted on the Risk Register for some time. As the risk has been mitigated by manually checking the data, this should have been removed from the Risk Register. Unfortunately, an IT solution had not been found. The Member enquired why this had been accepted instead of seeking an alternative IT supplier and requested a written report on this issue at a future HOSC. Ms Sanders reported that the Trust is confident in the data it has, although it now must be manually validated rather than being automatically accessible.  The Chairman suggested that a written report on this be brought to the May HOSC Meeting at the same time as the Quality Account.

RESOLVED that the Committee noted the written and verbal update.