An unannounced inspection of the hospital’s maternity service took place in October, following the death of Malyun Karama, in February this year.
The 34-year-old died while giving birth to her stillborn baby. She suffered a ruptured uterus after being given an overdose of misoprostol to induce her labour.
In a report following an inquest into her deah Coroner Mary Hassell said: “Abnormal observations were relayed by a midwife to a senior registrar, but the doctor failed to attend Ms Karama and instead ordered fluids. The uterine rupture would have been life threatening whatever the care rendered to Ms Karama, but if the doctor had attended immediately and had reviewed and treated appropriately, the likelihood is that Ms Karama’s life would have been saved.”
The CQC has yet to publish a full report on its inspection of the hospital but confirmed it had taken enforcement action and issued the trust with a warning notice.
The concerns relate to the trust being too slow to investigate and make changes after incidents of harm. It’s understood a panel to investigate Ms Karama’s death did not meet until June this year.
The regulator was also worried that patients who did not speak English were missing out on key information to spot signs and symptoms of potential problems during pregnancy.
Leaflets on issues like fetal movement, for example, were only available in English.
The trust has been given until 11 December to respond to the CQC and show it is making the required changes.
During the inquest into Malyun Karama’s death the coroner was told the protocol for using misoprostol had been changed and a medical review of patients like Ms Karama, who had already had one child, was now mandatory before the drug is given.
In a report sent to the Royal Free Hospital to prevent future deaths in August, the coroner said: “The Royal Free has not yet taken any steps to ensure that there is learning at a national level of the increased risk of rupture in a multi gravida mother [a woman who has a second or subsequent pregnancy] . The more widely known increased risk is simply of vaginal birth after caesarean.”
She added: “One of the midwives looking after Malyun Karama explained that there was no computer in the delivery suite and so she could not record her observations contemporaneously or without leaving the room. This is sub optimal.”
Nicola Wise, head of hospital inspection for London, said: "Due to concerns raised to us, CQC inspectors undertook a focused unannounced inspection of the maternity department at The Royal Free Hospital on 28 October 2020.
“As a result we have taken enforcement action to ensure improvements are made. We are unable to give further details at this time but will report on our findings shortly. All CQC’s action is open to appeal.”
A spokesperson for the Royal Free London said: “We would like to offer our deepest condolences to Malyun Karama’s family and to apologise for mistakes made in the care that was provided to her.
“Following the receipt of a warning notice from the Care Quality Commission, we have plans in place to improve the way we learn from incidents and the way we communicate with women whose first language is not English, and we would like to assure Ms Karama’s family that lessons will be learnt going forward.”