Basildon Hospital: Failings 'put maternity staff at risk'

Management at Basildon's maternity unit knew for 16 months about the excessive NOS levels before a serious incident was declared

Bosses at a maternity unit failed to keep staff safe over excessive nitrous oxide levels, a damning report reveals.

Staff at Basildon Hospital were not told for more than a year about test results which showed their exposure breached safety limits.

Some individuals had also not been honest, according to a report by Good Governance Improvement (GGI).

The trust's chief executive said it was "simply not acceptable that we took so long to act".

Also known as "gas and air" - or Entonox - NOS is used as pain relief for women giving birth.

The Mid and South Essex NHS Foundation Trust declared a serious incident over excessive nitrous oxide (NOS) levels within the maternity unit at Basildon Hospital in October 2022.

'Inadequate and ineffective'

The BBC had previously revealed how some staff had been exposed to almost 30 times the legal workplace exposure limit for nitrous oxide.

The GGI report described how there had been failure to act on a known risk to midwives and staff between July 2021 to October 2022.

The trust took seven months for the problem to be entered onto the risk register and its severity assessed.

According to the report there was an "inadequate and ineffective approach to risk assessment, risk escalation and risk management during the relevant period is a common thread throughout.

"There was ultimately an unacceptable delay in responding to and mitigating a serious risk that was reported to the trust by an external organisation (Cairn Technology) in June 2021", it continued.

The report said there had been failure to act on a known risk to midwives and staff between July 2021 to October 2022

Unstable leadership and management across different hospital departments added to the delay and the ineffective management of the problem, the GGI added.

"The management and senior leaders in maternity services failed to discharge their responsibilities in relation to staff health and safety," the report said.

"The individuals who were reported as being exposed during the testing in 2021 were not contacted following receipt of the results or offered occupational health support in line with trust policy."

The governance of medical gases at Basildon and across the trust was "inadequate and ineffective, with meetings frequently cancelled", the report added.

A poorly written business case "plagued by financial errors" had been drawn up to address the problem and the merger of three trusts into what is now one of the largest trusts in the NHS also contributed to the problems.

Staff were not always candid with the inquiry team, the report noted, and some continued to deny knowledge of their role in the situation despite being presented with evidence to the contrary.

Trust chief executive Matthew Hopkins acknowledged "weak governance" over the way the NOS problem was managed

The Health and Safety Executive (HSE) also investigated and found the law had been broken relating to information, instruction and training, and failure to review control measures following adverse monitoring results.

A HSE spokesman said: "A site visit was undertaken with an occupational hygienist specialist inspector and material breaches were identified during the investigation and the Trust received a Notification of Contravention letter.

"The Trust has addressed the breaches and there was no further action."

Trust chief executive Matthew Hopkins said: "While we now have robust systems in place and are confident that nitrous oxide levels are well within the safe limits, it is simply not acceptable that we took so long to act.

"We committed to commissioning an independent investigation to fully understand what went wrong and how we could ensure that it doesn't happen again."

He added that the report "confirmed that the main cause of the failure to act on the initial air quality report was weak governance processes and they have recommended that we carry out a full governance review. That has now been commissioned."