NHS Lewisham Clinical Commissioning Group

Wider context from the report

“(2) LSCS was required for the baby, due to lack of progression despite augmentation, adverse position and prolonged rupture of membranes with meconium. The decision was taken at 20.00 hours, but delivery was not possible until 21.40 hours, as theatres were busy. This delay of 1 hour 40 minutes for a category 2 section was 40 minutes outside the Trust’s own guidelines. (3) The consultant obstetrician reported that this delay, which occurred out of hours, in a unit with over 4000 births per year was unacceptable. It worsens the potential impact, carrying a higher risk of brain damage or death of babies, if there were several emergencies at one time. Staff were reluctant to use the second out of hours (non obstetric) theatre as they cannot then respond to a category 1 emergency. My expert obstetric witness, ████████ of Kings College Hospital, gave an opinion that the out of hours theatre access created a real risk of preventable death, especially with the increasing rate of performing LSCS. He advised me that I should be concerned and bring the matter to the attention of the Trust. (4) Whilst the Head of Midwifery reported management changes and compliance with CNST assessment, she did not provide assurance that the theatre capacity had been increased out of hours. Furthermore it was reported that the Trust is shortly to be disbanded and a new Trust is being formed by merger with another. This may lead to service configuration changes. She reported that the future obstetric services were under review. (5) I concluded that a real risk existed that I should report to the Trust and the commissioning body, to ensure that it was fully appreciated and given appropriate priority in the service reconfiguration planning. ”