THE reviewers of maternity services at the Falkland Islands hospital the King Edward Memorial VIII Hospital have said there is “evidence of improvement” in the service from when they last visited, nearly two years ago.
Dr Sophia Stone, a consultant obstetrician and specialist in maternal medicine at University Hospital Sussex, along with Heather Woods, a specialist midwife, have been undertaking the review two years after the “avoidable” death of baby Aspyn.
A number of failings at the King Edward VII Memorial Hospital (KEMH) were identified by the Coroner after a week long inquest earlier in 2025 which were “causative” to the death.
Prior to the inquest, an internal and external review of the circumstances surrounding the incident took place, which led to a 42 point action plan being drawn up. The Director of Health and Social Services John Woollacott said to Penguin News (PN) in March this year that the points from the action plan would create a “robust and safer system.”
PN asked the reviewers whether the service they had reviewed was “robust and safer” than it had been on their previous visit, Dr Stone said, “yes but it’s a work in progress. It can always be more safe.”
At the time of speaking to the two clinicians they were still in the process of undertaking the review, the report of which they hope to submit within a few weeks. This report will be made public. Dr Stone commented that they had seen changes in the hospital since their last visit, “it feels like a very different environment, the team are working more collaboratively across the whole hospital.”
When the two last visited the KEMH in March 2024 Dr Stone continued that they “uncovered more systemic problems, it wasn’t necessarily down to individuals it was more a culture of not working together, very separate departments within the hospital.”
Ms Woods added, “there was a lot of human factor problems and issues like working collaboratively, communication fails. And there were some training and upskilling needs that we identified as well.”
Continuing Dr Stone explained that maternity services are a “fast moving field” at the moment “in terms of national recommendations” that have been made. A lot of the recommendations they made in their 2024 report were to bring practices in line with changes that had happened in the UK.
She explained that one document, Saving Babies Lives, looked at a number of different areas throughout pregnancy in order to reduce perinatal mortality, “it’s really bringing all those messages across to the Falklands and making sure that the team in the Falklands remain as up to date as possible.
“It was things like that we identified that probably hadn’t been happening as robustly as could have been. At the time we put it to the team that actually… everybody should consider themselves part of the maternity team so that when an emergency occurs it’s all hands to the deck.”
Action plan
recommendations
Speaking of the changes that have taken place since their first report, Dr Stone said that the team have done “enormous” work to improve timescales in emergencies, including through simulation training, “those kind of aspects have helped improve safety enormously.”
About 38 of the 42 points have been addressed in the action plan to date. It was explained that some have been rated blue to note that while it was complete, there was still ongoing scrutiny needed. Dr Stone confirmed that the vast majority were in that category, with the pair giving further recommendations on some of these points.
Ms Woods added, “there were not many that we thought they could probably do with a bit more work.”
Dr Stone added that “it is work in progress, I think the work never actually stops. It’s the same in our own Trust. There are lots of things that they still need to do better and we will highlight them.”
The reintroduction on handheld maternity specific notes was recommended during their last visit. Dr Stone explained that while the notes are now “much better” there were still occasions where hospital notes were used and printed out to be slotted into the booklets rather than filling out the specific boxes.
Ms Woods explained that using the handheld notes “standardises the process” which then “ensures that nothing is missed.”
The recording of information during antenatal appointments was criticised previously, but Dr Stone explained that now “there’s far more consistent recording of blood pressure, urine analysis and fundal height measurements where there should be.”
She added that serial growth scans have also been introduced “which is actually better care than you receive in the UK.” She continued that these scans are more likely to pick up any problems with fetal growth.
An improved system of antenatal appointments was also noted by the reviewers who explained that the scans and the antenatal clinic have been combined, as well as support being provided by a dedicated medical officer. Following these appointments a multidisciplinary team meeting including ultrasound technicians, midwives and medical officers to discuss current patients is held, “this never happened before” Dr Stone explained, “they discuss each of the women in turn, where they’re at and what the plans are… everybody has a voice at that meeting and so that represents safe, good quality care.”
During the interview with Mr Woollacott in March he referenced “encouraging a culture of open challenge” amongst staff, with the ability to question decisions if there were concerns.
PN asked Dr Stone and Ms Woods whether they had seen this during their visit, and whether it was their view that team work was evolving. “It seems to be” Ms Woods responded, “we’ve also done a staff survey and asked that question and overall it was more than 50% of people said yes…
“We’re going to feed all of this back and hope that they maybe build on that also.” Ms Woods explained that the survey was sent to staff members with any input into maternity care, not just the immediate maternity team, “perhaps people on the fringes feel differently to that core body of people, so it’s just making sure everyone feels that way.”
Ms Woods continued to explain that this is not an issue just found in the Falklands, “it’s challenging at home [in the UK], is the healthcare assistant going to feel happy to say to the consultant, ‘hang on a minute’? It’s always challenging in every department everywhere.
“We’re hoping the culture is changing.”
Dr Stone added that “it’s certainly more positive. I agree it’s not 100%, we’d like to see 100%, maybe we won’t ever achieve that but it’d be good.”
Pre pregnancy planning
The team explained that while their last visit had very much a focus on labour, care and urgency, they didn’t have chance to look at high risk pregnancies and overseas transfers, explaining that in this review recommendations will be made about this aspect of maternity care.
The pair spoke about “who, how, when those transfers take place” but also recognising that, “if you’re leaving your partner, children behind for a long period of time and you’re isolated in the UK that’s not going to impact well on their mental health, physical health” Dr Stone said, “it’s getting that balance right.”
They discussed initiatives that are happening in the UK around pre pregnancy and bringing those conversations to the Falklands looking at “optimising health and care so diet, lifestyle, exercise, folic acid… reviewing their medical history, their medication… also identifying who would have to go overseas so that they take that on board when they’re thinking about children and how it’s going to impact their families.” Dr Stone explained that while the presence of some risk factors meant overseas treatment would always be better for some patients, but in certain cases steps could be taken to modify other risks to avoid this.
Unique environment
The “unique environment” of the Falklands was mentioned in the terms of reference for the review, with it stated that any recommendations had to consider this.
PN asked Dr Stone and Ms Woods how much impact they felt the Falklands in itself had on the ability to deliver maternity services effectively.
Ms Woods responded that “in terms of a model of care for low risk women, it’s amazing. It’s what we’d all love to do in the UK, have a continuity of care team, the small caseload where you can get to know your patient, you can see them through pregnancy, birth and then postnatally. There’s loads of evidence to say that it’s the safest model of care for low risk women, and absolutely achievable here.
However she went on to explain that in case of emergencies or having patients with risk factors “you’re really remote.”
“It’s trying to balance it out, not over react, not under react and make sure it suits the population. We’ve tried to be really balanced to try and consider all of that when we’re making the recommendations.”
The pair agreed that while the easy thing to do would be to send anyone with risk factors overseas, “that does feel devastating in so many ways and costly. Striking that balance is difficult.”
Further recommendations
While the report is not yet complete, Dr Stone mentioned two other factors they felt should improve. The first being incident reporting, “has to be more robust and learning from those incidents.”
The second was the introduction of a maternity champion to allow service users a voice, “it’s really important that there is somebody from outside the hospital who attends on a regular basis and hears about what new initiatives are and what the problems are and is able to then feed that back to everybody out there.
“I think a lot of the mistrust and the loss of confidence, I suspect, comes from hearing the horror stories but not hearing about the change that’s taking place to make the maternity care safer and better.
“There really is a genuine wish to want to do the right thing for women and certainly that’s what we’ve seen this week.”
Maternity services then v now
When asked how maternity services in the Falklands had evolved in the 18 months or so between their two visits, Dr Stone responded, “there’s definite evidence of improvement, evidence of good quality care. I think the importance is in ensuring that the maternity team are given the opportunity to continue on a regular basis to upskill and spend some time in the UK clinically and do all the required training.”
She went on to speak about the upgraded equipment including a CTG machine and a new ultrasound reporting system, “but it needs somebody to interpret those properly and having interpreted and identified a problem to make the correct steps at that point to get the pregnant woman to safety, whether that is abroad or delivered.
“Without that continuing training and keeping up to date with knowledge it will lapse again.”
Dr Stone added that continuing external scrutiny would be one of the recommendations made in the report they were compiling, in order to “help drive forward that safe care.”
