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Investigation raises questions over safety at Queen’s hospital in Romford, Essex after deaths of Violet Stephens and Sareena Ali The deaths of two women shortly after giving birth have raised questions about the safety of care at an NHS hospital which boasts the largest maternity unit in the country. Violet Stephens died at Queen’s hospital in Romford, Essex, in April, just one month after a review by the care watchdog said Queen’s was failing to meet essential maternity standards. An independent investigation into Stephens’s death, seen by the Guardian, reveals that she saw at least 30 different healthcare staff in the last three days of her life, including five consultant obstetricians, 11 junior doctors and 12 midwives. She was known to be at risk – two previous babies had been delivered by caesarean section because of complications linked to high-blood pressure – but she did not get the standard of care to which she was entitled, says the report. “The number and extent of service provision weaknesses revealed by this investigation casts doubt on the organisational integrity of the maternity services,” it says. Stephens’s death followed that of Sareena Ali in January. Ali, who was having her first baby, died of a heart attack brought on by a ruptured womb. She had been left without midwife support for two hours. While the Care Quality Commission (CQC) inspectors were in the maternity unit – failing it on six different safety standards – Ali was lying on a life support machine in another part of the hospital. The CQC officers were not told. Queen’s, which is part of Barking, Havering and Redbridge NHS Foundation Trust, says it is doing all it can to improve maternity care. But Sarah Harman, the solicitor representing the families of the two women, as well as around 20 less serious complaints, said: “On the basis of all the cases coming forward to me, this is a maternity department that is not providing safe care.” The CQC report in March demanded “immediate improvements” to ensure the safety of women giving birth at Queen’s, warning that it was short-staffed, midwives were under-skilled and some equipment did not work. Queen’s responded that it was hiring 49 more midwives, half of whom had already been recruited. But the independent inquiry into Stephens’s death, dated July, suggested there were still fundamental problems in the maternity unit when she died. The independent “serious untoward incident” inquiry into her death, carried out by a professor of complex obstetrics and a senior midwife, found that Stephens had suffered severe pre-eclampsia in her fourth pregnancy, as she had in her earlier ones. Pre-eclampsia is one of the most common conditions that kill women in childbirth. In Stephens’s case it became particularly serious because her liver was affected. The report found her case was not well managed and there were delays in giving her a caesarean and blood transfusions. In the antenatal clinic, she saw six different doctors and midwives. In the last three days at Queen’s, no less than 30 different healthcare staff were involved. It is well-documented, said the report, that the more handovers of information and responsibility there are, the greater the risks for the patient. “The severity and deterioration of VS’s condition was not recognised or managed in a co-ordinated way,” it said. “The tragedy at the centre of this investigation is the death of a mother, which most profoundly affects her family, friends and the three motherless children left behind.” The report found evidence of good care, kind staff and effective working but “significant factors were identified which prevented VS from receiving the standard of care she was entitled to expect and to which the trust aspires”. Ali was 27 when she died at Queen’s hospital in January. Her husband Usman Javed has said she was in agony in the labour ward, but midwives did not respond to his requests for help. She suffered a ruptured womb, which brought on a heart attack. Her baby was delivered by caesarean section but born dead. At one point a team tried to resuscitate Ali with a mask that was not attached to the oxygen cylinder. “When I first took on Usman’s case, I thought it was a tragic and isolated incident,” Harman said. “In the best hospitals that run good maternity services, a tragedy can arise which is not in line with the care they provide.” Other complaints Harman is pursuing against the hospital include two allegations of caesareans carried out without enough anaesthetic and women having to be re-admitted with serious illnesses because they were discharged too soon. Queen’s sees nearly 7,000 births a year. The CQC inspection was a “compliance review” – designed to ensure the hospital had met all the necessary standards in maternity and midwifery care. It had not. The CQC said improvements were needed in six essential areas, including the safety of equipment, staffing numbers and safe and appropriate care for women. Inspectors said they had “major concerns” over delays in going to theatre when a caesarean was needed, pain relief and women being left alone in labour. Staff spoke of being “very stretched” at busy times when it was “like working on a conveyor belt”. Averil Dongworth, chief executive of the trust, said of the report she commissioned into Stephens’ death: “I was very concerned to hear that we had failed to give this seriously ill woman the high standards of care that she should have been able to expect from us and would like to apologise for this on behalf of the trust. I’m determined these issues are addressed so every woman can be confident about our maternity service.” Following the death, staff held a special conference to learn lessons and new guidelines were put in place. The hospital now has one of the highest levels of specialist doctor coverage in the country and enough midwives for one-to-one care, Dongworth said. “These changes are part of a comprehensive action plan to improve our maternity service across the board and make sure every woman can have a good experience of childbirth in the safest possible environment.” A further review of services by the CQC is underway and will report in a few weeks’ time. Health NHS Childbirth Health & wellbeing Sarah Boseley guardian.co.uk