Another indication of poor NHS lesson learning.
Yet more pressure on NHS Maternity Units today.
This time in Milton Keynes, where the local Coroner reported the Trust involved to the Department of Health, asking for an investigation into why a senior midwife’s views had been disregarded. Apparently, a registrar, after discussion with a consultant on the phone, had ignored the midwife’s advice that a emergency caesarean was required and tried an assisted delivery instead (sounds familiar). The baby had died within an hour of delivery.
To quote the Healthcare Commission’s report regarding learning lessons;
“… in all the clinical governance reporting structure, we could find no evidence of serious untoward incidents from the maternity department or elsewhere in the trust having been highlighted and traced all the way up from ward level, through the divisional structure, to the Healthcare Governance Committee and the trust’s board. We could also find no evidence of the resolution of issues, learning or other feedback being passed back down the line to ward level.”
Frightening.
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