FAI determination calls for review of staffing of maternity units at weekend

South Wales Guardian

4 days ago

Freya Murphy was born on July 21 2018 at 9.31am in Queen Elizabeth University Hospital Glasgow, and died there on July 28, aged seven days and 12 hours old.
The cause of death was given as global ischemic brain injury associated with acute chorioamnionitis, and a fatal accident inquiry was held at Glasgow Sheriff Court in November.
First-time mother Karen Murphy, 32, from Cambuslang, South Lanarkshire, and husband Martin Murphy, called for several recommendations to be made, including screening for Group B Streptococcus (GBS).
However sheriff Barry Divers said that there were 'no defects in any system of working which contributed to Freya's death' and said the death 'could not realistically have been avoided'.
NHS Greater Glasgow and Clyde said in a statement that the care was 'below the standards expected' and that a recommendation had already been adopted.
The sheriff's determination made recommendations that the health board should review staffing levels across all shifts to ensure that its labour wards, post-natal wards, maternity assessment units and other hospital maternity related areas are adequately staffed at the weekend and in the evening.
The measure was to have provision in the case of an emergency where two patients require admission to theatre at the same time, for the opening of a second operating theatre.
It also recommended that the health board should formerly request that the United Kingdom National Screening Committee (UKNSC) give urgent consideration to a review of whether pregnant women routinely be offered screening for GBS.
If such a review is under way, then a copy of this determination should be provided to the UKNSC for consideration, according to the determination.
The determination said: 'It was clear on the evidence that all those clinicians (doctors and midwives) who spoke to their involvement with Freya, were motivated in their actions by doing what they thought was best for Freya and Mrs Murphy.
'It was obvious during their evidence that Freya's tragic death has left a mark upon each of them in different ways which will last for the rest of their professional careers and beyond.
'For the reasons I have explained, I have not been able to make all the findings or recommendations which they sought.
'However, I hope that the entirety of this FAI process, including the preparation for the evidential hearing, the evidence which was led, the submissions made and this determination, has at least addressed the questions which they have about what happened.
'It was suggested that the adoption of routine screening for GBS would be a suitable tribute for Freya. I understand why that submission was made.
'However, if I might respectfully say, I do not consider that would be accurate, even if it were to happen.
'The real tribute to Freya is the obvious love carried for Freya by her mother and father, which love has no doubt been passed on to Freya's siblings.'
Dr Claire Harrow, deputy medical director for acute services at NHS Greater Glasgow and Clyde said: 'We would like to extend our sincerest condolences to the family of Freya Murphy, and once again to apologise for the distress they have experienced.
'The care Freya received fell below the standards expected and for this, we are very sorry.
'We have received the findings from the FAI. The recommendation for NHSGGC on staffing has already been implemented.
'In line with the recommendation on Group B Streptococcus, we plan to make a formal approach to United Kingdom National Screening Committee.'