Excess of neonatal deaths at Countess of Chester Hospital
An excess of neonatal deaths at Countess of Chester Hospital signal for the period June 2015 and July 2016, lead, after routine internal governance processes failed to identify a cause, to an invited external review published in November 2017. Internal review had identified unexplained events as well as deaths. The report notes this and found that staffing resources were inadequate, investigation into neonatal deaths uncoordinated, and commissioning arrangements for relevant services, including those for transport inadequate. It also recommended detailed case review of all cases. This resulted in May 2017 in police involvement and in July 2018 arrest of a nurse. Potentially 17 deaths and 13 unexplained collapses may turn out to be explained after all. The context includes that in March 2017 NHS England mandated a more structured approach to mortality review with resource implications.