Hospital told to improve safety probes a decade after baby deaths

A hospital in East Ayrshire has been ordered to improve the way it handles patient safety incidents in its maternity unit, almost 10 years after it was the centre of an investigation into baby deaths.

The report from Healthcare Improvement Scotland (HIS) made 16 requirements for improvement at the unit in Crosshouse University Hospital, near Kilmarnock, including for delays women faced when they contacted the triage unit.

It said some staff were reluctant to report patient safety events, and reviews into incidents took too long to the detriment of families.

NHS Ayrshire and Arran said it is committed to ensuring patients receive safe and dignified care at all times.

In 2016, a review was ordered into failures of care at the hospital after BBC Scotland News revealed there had been six "unnecessary" baby deaths at the hospital. NHS Ayrshire and Arran was told to improve the way it investigated adverse events.

Last year, the Scottish government said it would carry out a national review of maternity care after another BBC investigation revealed ongoing safety concerns across several maternity units.

In total, the latest report made two recommendations and 16 requirements.

Other areas for improvement include flushing of infrequently used water outlets and improvements in the cleanliness of patient equipment.

The HIS report also highlighted 10 areas of good practice including "positive and respectful" interactions between staff and women, families and babies and that staff felt well supported in an under-pressure environment.

HIS chief inspector Donna Maclean said: "Women within the unit told us they felt listened to and supported in making decisions about their care – women described positive experiences of communication and compassionate interactions with staff.

"However, we raised concerns regarding potential delays to care for women accessing maternity triage and potential gaps in incident reporting, which may impact on the learning from adverse events and reducing opportunities to improve safety."

This report comes after a routine unannounced inspection of the hospital in October last year.

These inspections were introduced for all 18 obstetric units in Scotland, after an independent review that followed a spike in the deaths of newborn babies.

In 2016, a review was ordered into failures of care at Crosshouse University Hospital after BBC News revealed there had been six "unnecessary" baby deaths.

One of those deaths, was Fraser Morton's son Lucas.

After his death, external reviews and reports by the health board indicated a failure to diagnose pre-eclampsia, delays and a failure to correctly monitor the baby's heartbeat - and a failure to alert senior members of staff despite being unable to hear the baby's heartbeat for 35 minutes.

Fraser Morton told BBC Scotland News: "The failings that contributed to Lucas' death, every one was identified in a previous action plan or a review into Ayrshire and Arran's adverse events system.

"If those action plans were properly implemented, I believe Lucas may have been here today."

He said while there are "some things to be pleased about" in the report, not enough progress has been made.

"You still have the NHS marking their own homework, there are no powers, there is no independent scrutiny body or healthcare regulator.

"I don't see what the difference is between a recommendation or a requirement. Both can be ignored."

Nurse director Jennifer Wilson said the health board acknowledges the report and the areas where further improvements are needed.

She said: "NHS Ayrshire and Arran is committed to the provision of high standards to ensure our patients receive safe and dignified care at all times.

"Our teams have a strong focus on ensuring that improvements are made to deliver the best possible care across health and social care services."

Health secretary Neil Gray said the HIS inspections were "helping to inform" a review by a new maternity and neo-natal taskforce announced by the Scottish government last year.

Gray said the taskforce - due to be led by public health and women's health minister Jenni Minto - had met, but the review was yet to begin.

"I'm confident in its (the maternity unit's) safety and I'm confident NHS Ayrshire and Arran will respond to the recommendations in a timeous fashion," he told the BBC's Radio Scotland Breakfast programme.

"The government takes very seriously, not just the HIS inspections, but also the issue that can sometimes lie underneath them around culture.

"All acute maternity services are due to be inspected in the course of this year to ensure that we are getting the fullest national picture as to their safety and so we can ensure that any lessons that are required can be learned, not just locally, but nationally."