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Shake-up after woman’s tragic death exposed ‘inadequate’ maternity unit at Royal Free

Care Quality Commission delivered lowest possible rating

03 June, 2021 — By Tom Foot

The Royal Free Hospital in Hampstead

ROYAL  Free bosses say they have made urgent changes to the hospital’s maternity unit after it was branded “inadequate” following the death of a pregnant woman.

The Care Quality Commission (CQC) delivered its lowest possible rating after an unannounced inspection was triggered by warnings from St Pancras senior coroner Mary Hassell. Ms Hassell had written to the NHS trust about Malyun Karama who died in the Hampstead hospital in February last year.

The 34-year-old was given an excessive amount of misoprostol – a drug used to induce labour – while she was having a miscarriage. However, a doctor failed to attend to the patient despite being alerted by the midwife.

The coroner said that if he had acted on the warning “the likelihood is that Ms Karama’s life would have been saved”. The CQC – the health services watchdog – ordered “significant and immediate improvements” at the unit, particularly in the way it works with patients who do not speak English.


The CQC’s report said patient safety information in other languages was not available, meaning women with a limited understanding of English “were at higher risk of missing warning signs about their own, and their baby’s health”.

Bizarrely, a problem with the WiFi connection on the labour ward was found to have left staff not “always able to collect reliable data on the electronic patient record system”.

There were “several issues” with the resuscitation trolleys that contained expired medicine and equipment and had the wrong items on them, the inspection report said.

When asked, staff could not find a single scalpel on the antenatal or postnatal ward.

“We were not assured the appropriate equipment was available to staff when it was required,” the report said.

The trust did not have proper records about formal apologies and staff did not display a good understanding of the “patient population”.

For example, when CQC inspectors asked what were the most widely spoken languages on the ward other than English, staff replied “Jewish” and “Asian”.

The inspection, last October, called into question senior managers’ ability to run the department and why changes had not been made following recommendations from Ms Hassell last year.

“We were not assured the leaders understood and managed the priorities and challenges the service faced,” the CQC report said.

The New Journal understands an independent firm has been parachuted in to assess the management of the maternity unit following the CQC’s findings.

The CQC’s deputy chief inspector, Nigel Acheson, said: “We fully appreciate that hospitals in London are facing a particularly challenging time.

“However, due to the serious nature of our concerns, we served the trust with a warning notice.”

Overall, the Royal Free London’s CQC rating of “requires improvement” has remained the same.

A spokesperson for the hospital said: “Following the Care Quality Commission’s (CQC’s) inspection of the Royal Free Hospital’s maternity unit last year, the trust developed detailed plans to improve the way we learn from incidents and the way we communicate with women whose first language is not English.

“Last week, the CQC carried out its follow-up inspection and they will report on their findings in due course.”


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