AN investigation into maternity services following 10 serious incidents, including five stillbirths, at Warrington Hospital has found the department was short-staffed, deaths were avoidable and there was often a breakdown in communication.

The report from the Royal College of Obstetricians and Gynaecologists was completed months ago but hospital bosses have waited until all the families involved have had the opportunity to discuss the findings before it was released to the Warrington Guardian.

Findings of the report included poor risk assessment in three cases, misinterpreted cardiotocographs which contributed to 'foetal demise' in two cases and incorrect calculations made and failure to 'escalate concerns' in three cases.

The report said the clinical director described incidents in January 2014 as a 'serious problem' and the decision was made to treat all patients as high risk requiring them all to have electronic foetal monitoring.

He believed had monitoring been in place, previous deaths would have been 'avoidable'.

The move led to a 'breakdown' in the relationship between midwifery and obstetric staff which 'remained a problem' at the time of the investigation in the summer last year.

This in turn led to a 'culture of fear' which the writers of the report believed 'almost certainly made them behave differently with women who were having catastrophic events'.

Inadequate midwifery staffing issues were also noted during the visit.

The report added: "On a number of occasions, Warrington has had to close its maternity unit simply because of midwifery shortages and this situation has become increasingly frequent in the last two years.

"The Trust will need to understand the risk it takes when the labour ward is so poorly staffed with midwives."

In conclusion the report said it did not believe the unit was 'unsafe' but there was a number of training issues that needed addressing.

Warrington Hospital bosses said they welcomed the report and many of the recommendations put forward had already been adopted including a system called GROW (Gestational Related Optimal Weight) which improves the detection of foetal growth problems during pregnancy and can help reduce stillbirth rates.

A spokesman added the system has been accompanied with revised guidelines and training for identifying, managing and escalating cases and revised training around interpretation of readings from CTG (cardiotocography) which is used to monitor unborn babies during labour.

Work has also begun to explore options around creating a midwifery led unit, also known as MLUs, which are separate units designed specifically for low risk births and recommended by investigators.

The unit is also currently advertising for a new consultant midwife and a spokesman added staffing levels had also been increased.

Karen Dawber, director of nursing at the hospitals, said: "We commissioned this report to give an outside expert perspective on our services after we had identified this cluster of stillbirths.

"We are now six months on and a great deal of progress has been made.

"Training has been strengthened as the report highlighted areas that it could be made better, staffing has increased and the concept of a midwifery led unit for women and families in Warrington and Halton is moving closer."

One concerned parent, who did not want to be named, added: “My baby and nine other babies died due to the repeated poor judgement of midwives at Warrington Hospital. 

"The Royal College report reaffirms what we already know, that the 'root cause in all cases was a failure of risk assessment by midwife and it was this failure that lead to the incidents'.

"It is heart breaking to know that a breakdown in communication led to attitude changes with the midwives which, as the Royal College feedback states, led to a behavioural change when dealing with women in catastrophic situations. This can never happen again."