Healthcare Safety Investigation Branch
We approached the Healthcare Safety Investigation Branch in Early April 2018 soon after the meeting we had with the Trust when we were all crystal clear that there were major issues to be looked at. It took two months of providing detailed information to them in order to get an investigation. Harry was born too early for their statutory maternity investigations as these only applied to to babies born from April 2018, so we were given a national learning investigation to look at themes that could be learnt nationally.
HSIB investigated and interviewed for 6 months and then published their report to the family and the Trust in January of 2019. This is an organisation that does not attribute blame, so their report may surprise you.
"Our teams work closely with patients, families and healthcare staff affected by patient safety incidents and we never attribute blame or liability to individuals."
You can download the HSIB report on Harry's death here.
Section 4. Summary of HSIB Findings
1. The mother had a prolonged latent phase, there was an opportunity to seek advice from the obstetric team at the time of rupturing the membranes to progress labour.
2. Earlier obstetric intervention and augmentation of labour may have prevented the labour from becoming prolonged.
3. From the point of transfer to obstetric led care the mother was not seen or reviewed in person at any time by a consultant obstetrician for the duration of her labour.
4. The DR C BRAVADO mnemonic is not recommended by NICE for the interpretation of CTGs, but it has been adopted by the Trust as part of their guidance on the assessment and interpretation of electronic fetal heart monitoring.
5. The CTG ‘fresh eyes’ review did not meet the requirements of the Trust guidance.
6. There was variation of opinion between the team in relation to commencing syntocinon due to the interpretation of the CTG.
7. The CTG categorisation of features were inconsistent and confusing, however this is unlikely to have contributed to the outcome.
8. The Trust recruited a locum doctor without providing induction or assessing competence level.
9. The locum was recruited into their first shift in the Trust on a night duty when additional support is less accessible.
10. A consultant should have been present in theatre at the time of the baby’s delivery in accordance with RCOG- Green top guidelines 2011 and Trust guidelines.
11. Managing the delivery of a baby who has an impacted head is a complicated procedure and requires experience and expertise, beyond that of a junior doctor.
12. The baby’s placenta was not retained in accordance with Trust Policy
13. The paediatric consultant did not make the junior team aware they were remaining on site and therefore available to support emergencies promptly.
14. The switchboard was not updated of the change of the on-call consultant paediatrician.
15. During the resuscitation roles were not allocated to support the timing of events.
16. The resuscitation team lost situational awareness and were therefore unaware of the length of time taken to establish a suitable airway and provide adequate oxygenation.
17. The Trust are not compliant with BAPM (2014) standards for Neonatal Care - the multidisciplinary team working in the level 1 unit should be provided with regular opportunities to update their skills within a level 3 unit.
18. The complexity of the birth, difficulties with resuscitation and subsequent hypoxic insult that culminated in the baby’s death should have prompted earlier referral to the coroner.
Bearing in mind this report was published to us and the Trust in January 2019 you will understand our surprise when on 14th June 2019, 6 months later, the CEO of the Trust, Susan Acott wrote to us and included the paragraph below, seemingly totally unaware that the report was complete and had been published to them in late January? Not only that, they had commented upon it and asked for changes, which were not accepted.
"The Healthcare Safety Investigation Branch (HSIB) are also carrying out an investigation and I want to re-assure you that the Trust will comply fully with that investigation and any further learning points that are highlighted, will be fully considered and implemented."
Following Harry's inquest HSIB were also asked to report to the Health Minister Nadine Dorries on what they had found at the Trust.
You can read their damning report here -
"The HSIB summary report highlights that from July 2018 to January 2020 HSIB commenced 24 investigations with East Kent, and from December 2018 engaged frequently with the Trust to present evidence of recurrent patient safety concerns in its maternity services. Despite repeatedly raising these concerns with the Trust, HSIB investigators continued to see the same themes reoccurring and in August 2019, asked the Trust to self-refer themselves to their clinical commissioning group (CCG) and the Care Quality Commission (CQC)."
Even after the Trust CEO Susan Acott wrote to confirm that the Trust had self-referred to the CQC and others; HSIB wrote directly to the deputy head of CQC to confirm they had actually written. This level of distrust demonstrates how the Trust were regarded even in mid 2019.
To make the point, August 2019 when HSIB were so concerned was 22 months after Harry's death. and 6 months before the conclusion of Harry's inquest when the CQC went in and inspected, only to find significant failings were still evident. It seems that maternity services were still unsafe for all of this time.