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‘Failure to act with candour’ over unsafe gas, report finds

Published on: 14 Feb 2024

There was an “unacceptable delay” and “failure to act with candour” in how a trust responded to a serious risk from staff nitrous oxide exposure, an independent investigation has found.

Mid and South Essex Foundation Trust found levels of nitrous oxide far above the workplace exposure limit at Basildon Hospital’s maternity unit during routine testing in 2021. However, staff were only notified and a serious incident declared more than a year later.

The exposure related to a mixture of nitrous oxide and oxygen, commonly known as gas and air, used during births. While short-term exposure is considered safe, prolonged exposure to nitrous oxide could lead to potential health issues.

Chief executive Matthew Hopkins has apologised, after a report by the Good Governance Institute said: “The inquiry found that there was an unacceptable delay in responding to and mitigating a serious risk that had been reported… As a result of this failure to act on a known risk, midwives and staff members on the maternity unit were exposed to unnecessary risk or potential harm from July 6 2021 to October 2022.

“While it is not possible to assess the impact on individual members of staff or patients from the exposure to nitrous oxide at this time, the inquiry found it was evident that the levels of nitrous oxide needed to be treated as a significant risk to health in July 2021, but this was not done until October 2022.”

The GGI report said there had also been a “failure to act with candour and transparency” after the initial air quality report in 2021, and also from some individuals when engaging with the inquiry. These individuals were not named.

It also said there was a lack of accountability, with some assuming others were dealing with the issue. It said: “This applied to many levels within the organization up to and including executives.” 

The issue was brought to the attention of interim chief executive at the time, Hannah Coffey, in October 2022 and a serious incident declared, the report added. It said the issue was taken seriously from this point onwards.

Mr 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.”

He said weak governance processes had been identified as the main cause of the failure to act, and the trust has now commissioned a full governance review. Other findings from the report included a lack of stability in leadership and problems with the management of medical gases.