Blackpool Victoria Hospital investigation as newborn mother sent home with vaginal pack still inside her
Described as a 'never event' the Vic's midwifery service is facing a probe by care bosses over what took place in July
By Shelagh Parkinson, first published on 9 September 2024
An investigation is underway after a medical swab designed to stop bleeding was left inside a patient after she had given birth.
The incident at Blackpool Victoria Hospital has been identified as a ‘Never Event’, which means it was a preventable safety risk.
A hospital report says the incident happened in July this year when a woman was taken into theatre after suffering a haemorrhage shortly after giving birth, in order to be examined under anaesthetic.
A Bakri balloon and vaginal pack were inserted to control the bleeding before the mother was transferred back to the delivery suite for further care. She was sent home with the swab still in place when it should have been removed.
The report, which was presented to a meeting of the board of the Blackpool Teaching Hospitals NHS Foundation Trust, says: “The Bakri balloon was removed, with no documentation of the vaginal pack being removed and the mother went home with this still in situ.
“The next day, the mother rang the maternity unit to inform that she had removed the vaginal pack and that she was not aware it was there. The mother was advised to bring the pack with her the following day to her appointment in the maternity day unit.”
While an initial review of the incident found some immediate lessons could be learned, the report adds: “A Patient Safety investigation is in progress and stakeholders including the CQC (Care Quality Commission) and ICB (Integrated Care Board) have been informed of the incident being a ‘Never Event’.”
The board meeting also heard Blackpool’s Maternity Unit has a shortfall of 11 midwives, but despite this members were assured the unit is safe.
Part of the reason for the shortfall is the increasing complexity of health issues from expectant mothers which puts more pressure on the maternity team.
A recent independent review had recommended a birth to midwife ratio of 21.3 births per midwife, whereas in 2022 the ratio was almost 23 births per midwife.
This was due to a 4.7 per cent increase in expectant mothers being in the highest risk categories with more than two-thirds being in the top two categories that need more complex care.
The report says: “The case mix is similar to many maternity units where there has been an increase in the acuity of mothers and babies during the past three to four years. “
The investigation comes after court proceedings took place against the hospital trust over a heavily pregnant woman being given an injection inappropriately to assist with contractions.
 | A guest post by
|