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Chester hospital's failings revealed in death rate probe involving higher risk babies

Hospital ordered review into greater number of deaths than it would normally expect

The women and children's building at the Countess of Chester Hospital.

Grieving parents have been shown the worrying findings of a review into increased neonatal mortality rates among higher risk babies cared for at the Countess of Chester Hospital.

Since last July the most poorly babies, with high dependency needs, have been looked after at Arrowe Park Hospital, Wirral, or another neighbouring unit.

This step was taken because the Countess wanted to understand why there had been a greater number of deaths than it would normally expect on its neonatal unit between January 2015 and July 2016.

Countess of Chester Hospital

The Countess commissioned an independent review by the Royal College of Paediatrics and Child Health and The Royal College of Nursing which found ‘significant gaps in both medical and nursing rotas’.

Staffing levels were sufficient for a level 1 Special Care Baby Unit but not for a level 2 Local Neonatal Unit providing longer term high dependency and some intensive care.

Countess of Chester Hospital, Chester.

It also found arrangements for investigating neonatal deaths ‘must be strengthened’.

Among the 24 recommendations were the need to review each unexpected neonatal death in the relevant period, strengthen the response to neo-natal death/near-miss investigations, to appoint two additional consultants, ensure the maintenance of skills of neonatal nursing and medical staff and to create a ‘children’s champion’ on the hospital board.

Ian Harvey, medical director at the Countess of Chester Hospital

Countess medical director Ian Harvey said: “We’ve acted swiftly to get the 13 individual external case note reviews completed as advised by the Royal College.

“This has been a detailed exercise, concluded within the last two weeks.

“This means that when we speak with parents we can now share full and accurate information, on an individual basis.

“We are desperately sorry for any distress or upset this review has caused.

“We know those families affected have been through so much already.”

Chief executive of the Countess of Chester Hospital Tony Chambers

Chief executive Tony Chambers said: “Throughout this we have never lost sight of the families bereaved by the loss of their baby, and they have always been our primary concern.

“It must have been devastating for them to lose their baby, and then face a period of not knowing.

“We are now able to share everything that we understand about what has happened here and our thoughts are with them.”

The Countess says changes to admission arrangements will remain in place until managers are ‘certain’ all recommendations have been actioned.

However, whether the hospital will return to its former status as a Local Neonatal Unit is unclear because of developments at a regional level.

The controversial draft Sustainability and Transformation Plan (STP) for Cheshire and Merseyside NHS, which was published in November, raised questions over whether neonatal facilities were about to undergo a radical reorganisation.

Chief executive of West Cheshire Clinical Commissioning Group Alison Lee

Alison Lee, chief executive of West Cheshire Clinical Commissioning Group, translated the wording at the time as: “What they are looking at, in terms of the numbers of babies born and how ill they are, it is probably better to get those units to work together and say it would be better to have one bigger neonatal unit that looks after sicker babies.

“That’s the sort of thing they are talking about.

“But that plan isn’t written.”

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