Mums and babies have died because of bad medical decisions, poor attitude and chronic staff shortages at Pennine Acute NHS Trust.

A secret report revealing woeful lapses in maternity care has finally been released after a fight by the Manchester Evening News.

Among the worst incidents are:

A very premature baby who was left to die alone in a sluice room

A mum who died of a ‘catastrophic haemorrhage’ after her symptoms were put down to mental illness

A baby who died because staff failed to identify their mother’s rare blood type

A woman who was left with a colostomy because her condition was missed three times

The report shows:

Mums were put at ‘unacceptable risk’

Long-term failures led to ‘high levels of harm for babies in particular’

Staff relationship breakdowns exposed vulnerable women and their families to unacceptable situations

'Real' concerns over the care of women in labour

Deaths and appalling permanent harm as a direct result of bad clinical decisions, chronic short-staffing and poor attitude

Repeated warnings over years had not led to substantial improvements

Sky-high compensation pay-outs for death and injury

The M.E.N. learned in July that an internal review had been carried out into maternity care at North Manchester General and Royal Oldham hospitals. Insiders told us it was ‘shocking’. But our requests for a copy were repeatedly side-stepped until the trust eventually stated in August that it did not exist. Following a three-month Freedom of Information battle - and the help of a whistleblower - we can now reveal the truth.

The review, carried out by Pennine’s new maternity director Deborah Carter and written for the board, outlined a string of avoidable deaths and long-term injuries caused by failures in care over many years - which had continued up to the point it was written.

Since then hospital chiefs stress they have put measures in place to address the problems, in large part as a result of the report itself.

But the document's disclosure starkly lays bare just how severe Pennine's failures had become.

It describes ‘clear evidence of poor decision-making which has resulted in significant harm to women’, along with ‘real issues relating to the management of women in labour’ that have ‘resulted in high levels of harm for babies in particular, which has significant life-long impact’.

The report links short-staffing to a series of deaths, including one baby who died because antenatal staff had failed to spot its mother’s blood type.

“The effect of poor staffing numbers in clinics has meant women have fragmented care, suffered long waits and not had appropriate management,” it says.

“One incident identifies that a baby died following birth because the mother was not identified during her antenatal care as being rhesus negative and given the appropriate treatment to prevent any adverse effects on her baby.”

It highlights continuously high numbers of locums on Pennine’s maternity wards – accounting for more than a third of staff – as enduring ‘over many years’, leading to critically low levels of specific skills among doctors.

“This can be seen through a number of incidents and one in particular, where following surgery a woman was taken back to theatre three times, but no effective resolution achieved or the diagnosis of faecal peritonitis made,” it says.

“The woman remained in hospital for several months and now has a colostomy.

“Further examples of this are spread over a number of years and in the recent months, demonstrating an enduring culture.”

The report also links bad attitude and a lack of compassion to deaths and harm.

In one case a mother died from a ‘catastrophic haemorrhage’ after staff ignored the symptoms of hypoxia, a condition caused by lack of oxygen.

Instead they allowed her to deteriorate for days, putting her symptoms down to mental health issues.

“It is clear that staff did not build the effective clinical picture from her or sending vital signs and laboratory results,” it says. “They preferred to focus on the fact that she was demonstrating bizarre behaviour, rather than understand its cause.”

Another appalling incident saw a tiny premature baby left to die alone in the hours after her birth, rather than being nursed as she passed away.

The baby had been born very early, just before the ‘legal age of viability’, meaning staff – as per guidelines – did not attempt to resuscitate her.

But the report says basic compassion was missing.

“When the baby was born alive and went on to live for almost another two hours, the staff members involved in the care did not find a quiet place to sit with her to nurse her as she died, but instead placed her in a moses basket and left her in the sluice room to die alone,” it says.

It continues: “Staff attitude has been a feature of a significant number of incidents, from the most basic reports of staff relationship breakdowns, resulting in women and their families exposed to unacceptable situations.”

That has led to an ‘embedded culture of not responding to the needs of vulnerable women’, it says.

All those families involved in serious incidents have since met with the trust’s head of midwifery, according to Pennine.

However the report goes further than outlining specific examples in which patients were let down, also pointing to fundamental long-term failures.

North Manchester General should never have been taking the number of high risk pregnancies that it had been, it says, and was only doing so because of a lack of beds at Oldham.

That had placed women at ‘unacceptable risk’.

North Manchester was also presenting ‘significantly’ high numbers of women suffering trauma as a result of caesarean sections, a pattern the report’s author said was clear through the trust’s incident log.

Meanwhile the heart rates of babies were not being correctly monitored, leading to millions of pounds in compensation pay-outs.

The report also highlights other specific clinical areas as a concern, including failure of staff to properly undertake basic observations and high numbers of mothers suffering perineal trauma.

Having looked at two dozen previous incidents, Ms Carter identified a series of ‘worrying repetitive themes’ across the department, including failures to monitor basic vital signs, poor documentation, key lab results left unchecked, critical missing information left off patient records, a ‘rigid mindset’ among staff who tended to view patients’ conditions as ‘uncomplicated’, repeated breach of safety procedures and little performance monitoring of the high numbers of agency staff on the trust’s books.

Read the report in full below, or click here to view/download it if you're on our app:

At the time of the report’s writing in June there had been 12 serious maternity incidents that had been reported and were still under investigation since the start of April, including one maternal death, two baby deaths and three still-births.

An M.E.N. FOI request for the number of ‘avoidable’ deaths was rejected because the trust does not record its data in that way, although it is now planning to change its procedures.

However Ms Carter found failures in many areas were clearly apparent through trends in the data Pennine does keep.

The trust received more legal claims and paid out more in damages than any other between 2010 and 2015, nearly half of them relating to mothers and babies - payouts which totalled more than £25m.

Three separate incidents - all of them the result of failures to monitor patients properly, particularly heart rates - saw payouts of more than £6m.

High numbers of staffing incidents in the year to May were due to ‘not enough staff’ and ‘poor staff attitude’, she said.

The report’s damning conclusions came despite a series of warnings about care in the department.

It points out that in 2012 the trust was warned about three specific problems by the Clinical Negligence Schemes Trust, which handles legal claims against NHS bodies: lack of labour ward staffing, lack of health record audits and a lack of process for flagging up risk to a higher level, including to the board.

All three areas remained a problem four years on, she said.

In 2014 an external investigation had also taken place into deaths in the unit following ten deaths in the course of eight months.

In January 2015 it concluded that while risk management was below standard in some cases, there had been no deficiencies in care.

Bosses launched an improvement plan the following summer.

However nearly a year later, Ms Carter wrote: “It is clear from the report that the issues the service faces are not new but have been enduring over many years.

“Attempts to focus on improvement have not challenged or impacted on some of the most fundamental aspects including culture, behaviour, staffing levels and skill mix.”

She recommended that an outside organisation be brought in to oversee the service – which is now taking place via Central Manchester NHS Foundation Trust – and that no more high risk pregnancies, which account for around 500 women a year, be seen at North Manchester General.

However it is understood trust bosses have chosen to focus on improving North Manchester’s services instead, since sending so many high risk pregnancies to Oldham instead was not considered sustainable.

The report was only obtained by the M.E.N. after repeated requests, first to the trust’s press office, then through the FOI - including an appeal to the Information Commissioner - and the help of a whistleblower, who first raised alarm bells in July.

Pennine claims its failure to release the report, which was heard by June’s board meeting in private as part of a wider review, was due to a ‘misunderstanding’.

Graham Stringer, MP for Blackley for Broughton who had long warned of serious problems within the trust, said the report was 'one of the most shocking' he had ever read.

"Pennine should have made this report public as soon as it went to the board," he added.

Six months on from Pennine’s damning maternity report, the trust say it is finally improving

The report uncovered by the M.E.N. was written in May and June of this year, when new management - from Salford Royal hospital - took over following a critical government inspection.

It was part of a wider in-depth review carried out in an attempt to find out all the problems faced by Pennine.

Professor Matthew Makin, medical director at Pennine, said considerable work has been done since to improve services, including the recruitment of more midwives.

He said: “Following the initial feedback from the Care Quality Commission inspection of the trust in late February, the new Salford Royal executive leadership team requested that the newly appointed divisional director for women and children’s services carry out an internal in-depth service review of our maternity services.

“This review was part of a wider diagnostic review and more detailed look into the organisation, the culture, our staffing pressures and operational service delivery.

“Our new trust chief executive and the senior team wanted to understand fully the issues and problems affecting services, and what urgent action needed to be taken to improve patient care and to make our more pressured services safer and more reliable.

“In addition to this internal management report written by the newly appointed director for women and children’s services in June, a further extensive review was carried out by midwifery colleagues from Central Manchester University Hospitals NHS Trust as part of their support and involvement in our improvement plan.

“Both of these reports identified the same issues that were already raised by the CQC in its formal inspection report published in August.

“The findings and recommendations from these reviews have been integrated into the Trust’s comprehensive improvement plan which is discussed monthly at every public board meeting.

“Our Improvement Plan sets out specific areas across our maternity services that the Trust is now addressing through increased investment, improved staffing, focused training and the appointment of a new leadership team to drive up quality, safety and performance.

“To ensure the trust can make real improvements, a small number of serious incidents which occurred over the last 12 months have also been referenced in internal reviews and used as part of our improvement plan for staff training and have been shared outside of the organisation.

“These cases were, like all reported incidents, investigated thoroughly at the time and the families have been contacted and met by the trust’s head of midwifery to apologise for any failings in care and to discuss the changes that have been made.

“The priority is for all of the trust’s services to meet the high standards that patients expect and deserve.

“We are steadily making the necessary improvements so that patients can receive reliable, high quality care across all of our services.

“Recruitment of additional midwives and a focus on clinical leadership continues to be the trust’s priority for maternity services.

“In addition to the appointment of a new head of midwifery, 31 new midwives started in post across our two maternity units at North Manchester and Oldham last month.

“In addition to 58 new midwives joining us since April, the new management team is being supported by Central Manchester NHS Foundation Trust, who are providing supplementary clinical leadership support in order to stabilise and strengthen services on the North Manchester site.

“We have fully reviewed our risk and governance arrangements including learning from incidents and complaints, and are making progress in improving the way we listen and involve our staff to address the long standing problems and challenges facing our teams.”

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