A report into the deaths of five women whose maternity care was overseen by the same hospital trust has found “best practice” was not always followed.
The patients at the centre of the probe into Sandwell and West Birmingham Hospitals Trust were deemed high-risk.
In one case, a woman was given treatment that worsened her haemorrhaging, the report said.
The trust said while there was no evidence the deaths were preventable, it was working to improve services.
External experts in childbirth and midwifery reviewed the women’s cases in conjunction with the trust, although the trust and not the independent parties published the report.
Its document states “five maternal deaths in our care over a two-year period” were examined, with four women dying while pregnant or during childbirth, and one within a month of giving birth. Outcomes for the babies are not addressed.
The trust incorporates two acute sites – Sandwell General in West Bromwich and City Hospital in Birmingham, where the main maternity services are based. Three of the deaths were said to happen “outside” a “hospital setting”.
While the report does not allude to causes of death, or detail individually each unnamed woman’s experience, it gives a broad overview of some circumstances, including instances of Amniotic Fluid Embolus (AFE) – a “rare” childbirth emergency in which the fluid enters the blood, causing major bleeding.
The trust said “care pathways” for the “high risk” women were complex, with its report concluding the care did not meet “best understood practice” in three of the five cases.
Two of the five cases, it added, “may give rise to lessons”.
In a statement, chief nurse Paula Gardner acknowledged the “pathways” inconsistencies, and saying the women’s care needs either related directly to the pregnancies or other medical conditions, she added the shortcoming “was not necessarily contributory”.
She said: “In four of the cases, the reviewers found no practice that would have impacted on the outcome.
“In one case, the urgent actions of the team were commended as they fought to save the life of the woman and her unborn child, and it is not possible to determine whether earlier treatment of severe bleeding could have made a difference to the outcome.”
The report notes an “erroneous diagnosis” was made in one case which saw treatment given to loosen a blood clot, which led to a “subsequent worsening of haemorrhage”.
Ms Gardner said while no evidence of preventable death had been highlighted, “in order to provide the best care possible”, measures would be adopted to “improve the maternity services further”.
The report recommended a new approach to dealing with postpartum haemorrhage – excessive bleeding within the first 24 hours following childbirth – and “mapping out” the journey of care for high-risk patients.
A spokesperson for NHS England and NHS Improvement said the investigation had been “robust and comprehensive” and was assured the trust was taking recommendations seriously.
The trust was rated “requires improvement” after its most recent inspection in March 2017.
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