Pregnant woman died after 'cultural bias' caused delayed care at Liverpool Women's Hospital

"Cultural bias and stereotyping" delayed the care given to a pregnant black woman who died, an investigation has found. 

The 31-year-old black African woman was taken to Liverpool Women's Hospital by the North West Ambulance Service on 13 March 2023.

Investigators from the Maternity and Newborn Safety Investigations (MSNI), the national body to improve maternity safety, detailed how the woman was suffering "acute" pain and was taken to the gynaecology ward. 

An ultrasound scan the following day found the baby had died, with the woman's condition deteriorating.

After her condition became critical, she was rushed to the Royal Liverpool Hospital where she died two days later.

The cause of her death was recorded as acute intestinal ischaemia - where the blood flow to the bowel is restricted - and thrombophilia and pregnancy. 

Although the coroner determined the cause of death was a "natural cause", an MSNI report into the incident 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". 

The report added: "This was evident in discussions with staff involved in the direct care of the patient."

The MSNI report, which was accessed through the Liverpool Women's NHS Foundation Trust's board papers published earlier this month, found there were "missed opportunities for escalation to gynaecology colleagues...when there was a suspicion of a bowel obstruction, and escalation to the anaesthetic team was not considered". 

The MSNI report said: "Decision making impacted upon the care that she received and with the level of pain that she experienced; earlier intervention to support addressing pain was required.

"There was an opportunity for an X-ray to be performed earlier and for CT imaging to be undertaken.

"Additionally, there were opportunities for an MRI scan to be discussed and a referral made to the Royal Liverpool Hospital at an earlier time." 

The report noted that these vital observations were not performed as the patient was being "difficult refusing to have her observations undertaken due to the amount of pain she was experiencing".

The MSNI determined this led to missed opportunities to detect deterioration and escalate concerns.

The investigators also found "the impact of the junior doctors' strike" and low staffing were among other factors that contributed to the delays. 

The hospital's response to the report also found: "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." 

A 2023 report by Mothers and Babies: Reducing Risk Through Audits and Confidential Enquiries UK (MBRRACE-UK) found between 2019 and 2021:

After receiving the MSNI report, the Liverpool Women's NHS Foundation Trust shared details of "the commitment and actions established to tackle systematic cultural bias and stereotyping with the care they provide".

The MSNI were satisfied with the response and closed the escalation. 

A final investigation report dated December last year found "a theme across multiple incidents relating to the management of deterioration and a theme relating to incidents that included an element of inequalities".

The hospital has since introduced a "focused anti-racism strategy and implementation plan" and a new programme for handling deteriorating patients.