The deaths of newborn babies, cancerous tumours being left untreated for months and a swab being left inside a woman during a caesarean section are among troubling incidents under review at Liverpool Women’s Hospital.
And NHS managers fear lessons have not been learned from previous incidents.
A Serious Incident Panel at Liverpool Clinical Commissioning Group (CCG), which monitors performance and safety at local NHS bodies as part of its role, made the worrying observations.
A report from CCG chief nurse Jane Lunt said: “There has been limited assurance in relation to triangulation of learning from previous never events and serious incidents and little or no reference in the reports to the Trust Local Safety Standards for Invasive Procedures (LocSSIPs); with recommendations made for the Trust to submit improved reports or strengthened action plans.”
Since the beginning of 2020, two babies have died after the insertion of a femoral arterial line – a tube inserted into an artery in the thigh to help take blood samples and measure blood pressure in patients who need extremely close monitoring.
The lines risk serious complications if the flow of blood to the limbs is restricted, which can result in the need for amputation.
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Previous reports have identified issues with the procedure and consultants failing to spot when the tubes are dangerously restricting blood flow.
The deaths of the newborn babies in the neonatal unit, on April 12 and June 9 last year, were both logged as ‘Serious Untoward Incidents’.
According to Serious Incident Reports to the hospital board, the first casualty, ‘Baby A’, had a femoral line inserted in its leg for just under 24 hours despite warning signs that something was wrong.
A log of the incident said: “The limb was documented as being pale/white and cool to touch on a number of occasions in the 24 hour period prior to the line being removed.
“There were evolving ischaemic injuries to both legs resulting in an unsalvageable right leg and likelihood of below knee or through knee amputation to the left leg.
“The condition of Baby A deteriorated and on 12th April 2020, unfortunately baby passed away.”
The Serious incident Panel felt there were “missed opportunities” to remove the line earlier but stressed this “may not have changed the outcome for this patient”.
The second incident occurred after the arterial line was fitted in a newborn baby boy who already been diagnosed with a blood clot, meaning it was unsafe for the tube to be inserted.
The reduction in blood flow caused by the combination of the tube and the blood clot caused an “irreversible” ischaemic injury to his leg.
The baby died nine days later, but it is not clear from the report whether the femoral line injury contributed to his death.
The panel said: “This occurred because of a failure in the handover of key information between two consultants.
“The injury was made irreversible by the delay in removing the line after evidence that the perfusion (blood supply) had been impaired by the line.”
According to the minutes of a Liverpool Women’s board meeting in November, Gaynor Thomason, then interim director of nursing and midwifery, said: “There were some contributory factors which had occurred in previous serious incidents such as poor documentation, lack of escalation and not adhering to LocSSIPS procedures.”
Other serious problems noted by the Serious Incident Review panel relate to how the hospital has dealt with abnormal scan results in suspected cancer patients.
In one case, reported in June, a consultant requested a woman undergo an MRI scan in six weeks time.
However an error meant the scan was instead booked for six months later, where it picked up a cancerous tumour in her lung.
In another case, a woman reporting post-menopausal bleeding underwent a scan on February 29, 2020, which picked up a suspicious mass.
However, her case was wrongly placed on the “benign” pathway meaning she underwent no further treatment until October – when a routine appointment resulted in the error being spotted.
A follow up scan revealed the devastating news she had endometrial cancer.
In a third similar case, the patient underwent a scan to Liverpool Women’s Hospital in November 2019 which found polyps, and later tumour markers were identified.
However she received no further treatment until September 2020 when she was taken to the Rapid Access Clinic with a “significantly enlarged ovarian mass”.
The woman underwent surgery on October 15, 2020, and was discharged home three days later.
Her ordeal was not over yet, and 11 days post-surgery she was admitted to the Royal Liverpool Hospital with sepsis, resulting from a bowel injury caused by the surgery at Liverpool Women’s Hospital.
She was later diagnosed with ovarian cancer.
Dealing with grief and loss
If you have been affected by any of the details mentioned in this story there are people who can help you.
Most people grieve when they lose something or someone important to them.
The way grief affects you depends on lots of things, including what kind of loss you have suffered, your upbringing, your beliefs or religion, your age, your relationships, and your physical and mental health.
Grieving is a totally normal process but there are way to get help if you need support.
Your GP is a good place to start. They can give you advice about other support services, refer you to a counsellor, or prescribe medication if needed.
Other incidents of concern in the reports include an error during a caesarean section in May, when theatre staff left a swab inside a mum and were forced to re-open her to retrieve it.
A review of the incident identified the root cause as “lack of leadership, supervision and training of junior Theatre staff, leading to the inadequate distribution of staff for complex high risk case.”
Liverpool Women’s Hospital has logged 23 ‘Serious Untoward Incidents’ in 2020/21 so far, up from 13 in 2019/20 and 17 in 2018/19.
Marie Forshaw, director of nursing and midwifery at Liverpool Women’s Hospital, said: “We take extremely seriously any incidents that result in harm to patients and are committed to learning and improving when we get things wrong in an open and honest way.
“The safety or our patients and the quality of care they receive is our top priority, and where improvements are required our teams work hard to implement those changes and put in place robust action plans to respond to any serious incidents when they occur for future assurance.”
A statement from Liverpool CCG said: “As a CCG we are committed to improving the quality of local services for patients.
“We work closely with all of our local NHS Trusts to help identify any lessons that can be learned and changes that can be put in place in those instances where things do go wrong, to help ensure that mistakes aren’t repeated.”