A report found staff at Homerton Hospital were slow to recognise patients deteriorating , and suffered breakdowns in communication . An investigation into a hospital where four women died in 12 months before or during childbirth has found a series of concerns , it has been revealed . Inspectors from the NHS 's London clinical senate found that staff at Homerton Hospital , Hackney , were slow at recognising patients were deteriorating , and identified breakdowns in communication . Their report identified common themes in some but not all of the deaths , including a lack of involvement from consultants . The findings came after two unannounced inspections by the Care Quality Commission , following the death of a fifth woman in January this year , reports the Evening Standard . The first fatality occurred in 2013 , when Pat Williams passed away following a Caesarean section procedure which she elected to have . A subsequent report found that she was over 40 , obese , had previously miscarried and had a large fibroid in her uterus . Adeline Keh , 40 , was the next to die in October the same year after she contracted a fatal infection following a Caesarean at Homerton . She was transferred from the east London medical centre to a specialist heart and lung unit in Cambridge , but died after she refused a blood transfusion because she was a Jehova 's Witness . A report into her death found that her refusal 'may have compromised the final medical intervention ' in order to save her life . It was listed as a cause of death alongside acute respiratory distress syndrome , sepsis and an infection of the Caesarean wound . The third and fourth deaths occurred in March and June last year , at which point the CQC began investigating , and the London clinical senate was called in after a fifth death in January this year . Such deaths are extremely rare - therefore it was viewed as unusual for a single hospital to have so many deaths in a short period . Adeline Keh , 40 , was one of five to die at the hospital , four of which perished in 12 months . She contracted an infection after a Caesarean , and refused a blood transfusion because she was a Jehova 's Witness . In the whole of England and Wales in 2013 there were just 47 maternal deaths during pregnancy , childbirth and the six-week period following birth - out of almost 700,000 deliveries . In response to the report , which was made public this week , Tim Melville-Ross , the chairman of Homerton NHS Trust , said : 'This issue is clearly one of real concern to us . We have to devote all of our efforts to learning lessons . ' Homerton chief executive Tracey Fletcher added that the report found no 'silver bullet ' would have prevented the deaths . In response to the findings , staff at Homerton have been given extra training and consultant cover on wards has been increased to 98 hours a week .
Four deaths occurred from July 2013 to June 2014 at Homerton Hospital . fifth woman passed away in January this year after giving birth there . NHS report found common themes in some but not all of the deaths . Staff slow to recognise patients deteriorating and failed to communicate .