A Nottinghamshire woman who died shortly after giving birth to her baby may have survived if earlier safety recommendations had been implemented, a report has said. Bernadette Horsey, of Beeston, went into a cardiac arrest and died shortly after her son, Tim, was born via a caesarean section at the Royal Derby Hospital on January 19, 2022.
Her case was one one of three maternal deaths - along with four cases of life-threatening cases - over a period of 16 months to be included in a review by the Healthcare Safety Investigation Branch (HSIB). The report into University Hospitals of Derby and Burton NHS Foundation Trust (UHDB) found issues with communication, staff shortages, a bullying culture between teams caring for mothers and babies, and delays to care.
The trust apologised to the affected families and said it has put a comprehensive plan in place to make the recommended improvements. The HSIB said while there was no common theme to the deaths, the trust had not implemented safety recommendations that were made after previous investigations.
