Published by BBC NEWS - 16th June 2022
General view of Milton Keynes University hospitalImage source, PA Media

Staffing levels contributed to drug errors at a hospital which had one of its maternity wards open for just three weeks in 2021, a report found.

Milton Keynes University Hospital (MKUH) reviewed 21 errors in an antibiotic given to newborn babies from August 2020 to October 2021.

The review, seen by the BBC, found “the main causal contributory factor was staffing” and the complexity of cases.

The hospital has apologised for the errors.

Medical director Dr Ian Reckless said: “It is important to note than none of these errors resulted in any harm being caused, but were no doubt upsetting and concerning for the parents and families involved and I would like to sincerely apologise for the errors and the distress they caused.”

The antibiotic gentamicin can be used to treat the potentially life-threatening infection sepsis, according to the Royal College of Obstetricians and Gynaecologists (RCOG).

The BBC obtained an internal MKUH “thematic review” of intravenous (IV) gentamicin errors through the Freedom of Information Act.

Pregnant woman sitting and holding her bump

Image source, Getty Images

The hospital has two maternity wards – wards nine and 10 – and while the expected staffing on the former was four midwives, on average there were only 2.5.

The expected staffing on ward 10 was two midwives, but on average there were none.

The review said: “Covid has significantly affected the staffing levels within the maternity unit in 2020-21, with staff shielding, isolating, sickness and maternity leave.

“The wards have been affected and ward 10 has been open for three weeks only in 2021 due to insufficient staffing.”

The hospital said following a “reorganisation”, ward 10 was now predominantly used to support increased capacity when maternity services are very busy.

The review also detailed “process issues” with Gentamicin, including a lack of “alerts or ‘barriers’ to stop staff doing the wrong thing” and a laptop in the intravenous preparation room “that overheats and doesn’t always work”.

The investigator concluded “the main causal contributory factor [to the gentamicin errors] was staffing and acuity and this is impacted by the process issues identified”.

“There were 16 different recommendation/actions taken to reduce the baby IV incidents, however, the number of reported remains consistent each month which demonstrates the causal contributory factors or action plans were not effective enough to mitigating the risk,” the report found.

Dr Reckless said: “Staffing challenges in maternity services are an issue currently being faced in the NHS across the country.

“Acuity – referring to the complexity of obstetric care which is required for each person admitted to the ward – was further identified as a contributory factor in the review.

“During the period the review encompassed, we saw an increasing number of women and families in maternity services who required complex care packages.

“This complexity increases the amount of clinical support required to keep those patients safe.

“Patient safety is, and will always remain, paramount to everything that we do and following the findings in the review, we have taken extensive action to minimise the risk of similar incidents happening again.”

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