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“Cultural and ethnic bias” delayed diagnosing and treating a pregnant black woman before her death in hospital, an investigation found.
The probe was launched when the 31-year-old Liverpool Women’s Hospital patient died on 16 March, 2023.
It also found “the impact of the junior doctors’ strike” and low staffing were among factors that delayed recognising how ill she was.
The hospital said it had made “immediate changes”.
Investigators from the national body the Maternity and Newborn Safety Investigations (MSNI) were called in after the woman died.
A report prepared for the hospital’s board said that the MSNI had concluded that “ethnicity and health inequalities impacted on the care provided to the patient, suggesting that an unconscious cultural bias delayed the timing of diagnosis and response to her clinical deterioration”.
“This was evident in discussions with staff involved in the direct care of the patient”.
The hospital’s response to the report also said: “The approach presented by some staff, and information gathered from staff interviews, gives the impression that cultural bias and stereotyping may sometimes go unchallenged and be perceived as culturally acceptable within the Trust.”
Liverpool Riverside Labour MP Kim Johnson said it was “deeply troubling” that “the colour of a mother’s skin still has a significant impact on her own and her baby’s health outcomes”.
‘Stereotyping’
The woman, who was 18 weeks’ pregnant, was taken to the hospital by ambulance on 13 March, 2023.
She was suffering “acute” pain and was taken to the gynaecology ward.
A scan the following day found her baby had died, and after her condition became critical she was taken to the Royal Liverpool Hospital and died two days later.
The medical cause of death was recorded as acute intestinal ischaemia, a medical emergency caused by the blood flow to the bowel being restricted.
The investigation into her death found hospital staff had not taken some observations because the patient was “being difficult”, according to comments in her medical notes.
The MSNI probe went on to raise concerns about “the impact of systemic cultural bias and stereotyping on the provision of safe and effective care” in both the woman’s case and that of another black woman whose death from sepsis in August 2023 is still under investigation.
“The approach presented by some staff, and information gathered from staff interviews, gives the impression that cultural bias and stereotyping may sometimes go unchallenged and be perceived as culturally acceptable within the Trust,” the MSNI told the hospital.
The hospital said it had since reviewed other previous incidents “which included elements of inequalities” and had introduced a “focused anti-racism strategy” and new ways of handling deteriorating patients.
Dianne Brown, chief nurse at Liverpool Women’s, said: “We want to extend our sincere condolences to the family involved in this tragic case.
“We are absolutely committed to learn, improve and embed change to ensure that no woman experiences any detriment in her care due to her ethnicity.”
A report last year by Mothers and Babies: Reducing Risk Through Audits and Confidential Enquiries UK (MBRRACE-UK) found that between 2019 and 2021, woman from black ethnic backgrounds were four times more likely to die during pregnancy or immediately afterwards than white women.
Mrs Johnson said “urgent action” needed to be taken.
She said: “I will be contacting the hospital to demand answers about what they are doing to ensure this never happens again.
“I had my own twins at the Liverpool Women’s Hospital, while I had a positive experience it is terrifying to think how easily that could have been different.”
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Published17 December 2023
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