THE deaths of three pregnant women at Northwick Park Hospital were "probably unavoidable" and cannot be blamed on the maternity unit, a long-awaited report has said.

In May, Fiona Wise, chief executive of North West London Hospitals NHS Trust, asked an independent panel to investigate the fatalies, which occured between June 2007 and March 2008, along with two other non-fatal incidents and seven other incidents.

The resulting report - published on Tuesday - concluded: "The recent cluster of maternal deaths... is not the result of deficiencies in care."

But the panel, which comprised medical experts and directors from local Primary Care Trusts, did make some "essential recommendations" after scrutinising the times where something went wrong - and the way the trust then investigated.

The report said: "They were all high-risk cases; four of the women were non-Caucasian and communication was difficult for language, cultural or clinical reasons.

"None of the deaths or SUIs (serious untoward incidents) could have been prevented by better attention to current guidelines or protocols.

"In the three fatal cases, however, there were opportunities for better high-level clinical care in interpreting and reacting to apparently 'minor' symptoms.

"Consultant obstetrician involvement in these cases was limited to the labour ward and was much less before or after the intrapartum period (during delivery).

"The non-fatal SUIs revealed deficiencies in communication and co-ordination between obstetrics and other specialties in the hospital."

Between 55 and 60 per cent of mums going to the hospital are considered "high-risk" by the NHS.

Mrs Wise said: "I'm pleased about the balance of the report. On the one hand, it recognises the hard work of the staff and the very good care we give.

"On the other hand, it recognises that these were very tragic cases and it would be wrong of us to be complacent and that we must continue to do our best and make improvements all the time.

"The areas of good practice outweighed the recommendations. Throughout, it is quite clear there were no defencies of care in these deaths."

Mrs Wise said the fact that the number of births facilitated by the hospital -5,200 a year - had not dropped in response to bad publicity in recent years showed that mothers-to-be still had confidence in the quality of care provided.

She added: "What I would say to women in Harrow and Brent is, there are two things they can do to help us: book into the maternity department on time and secondly, express your concerns or worries at the earliest stage possible."

Northwick Park Hospital was only lifted out of special measures in September 2006. These had been imposed by the Secretary of State for Health after the hospital suffered 10 maternal deaths between 2002 and 2005.

The trust has since invested £19m in its maternal ward and at the end of the month its board is due to sign off an action plan - drawn up in response to the panel's recommendations - that pledges to:

recruit 20 extra midwives;

consider employing two extra consultants and review on-call rota;

introduce more training for consultant obstetricians;

recruit two new supervisor of midwives;

write a business case for a multidisciplinary perinatal mental health service; 

develop community care packages for vulnerable mothers;

consider creating 'clinics' where obstretricians can more readily contact specialists from other departments;

expand maternity unit triage facilities;

review guidelines of identifying and caring for high-risk women;

undertake a publicity drive to promote maternity services;

review size of antenatal clinic space.

Nigel Ellis, head of investigations at health watchdog the Healthcare Commission, said: "The death of a mother during childbirth is a tragic event. Our deepest sympathies go out to the families of the three women who died in the past 16 months at Northwick Park.

"We believe that the trust has responded appropriately to the deaths. This review was sufficiently independent and robust.

"We note the findings that the deaths did not result from deficiencies in care, although the review did highlight some important areas for improvement.

"This is a very different trust to the one we investigated three years ago. Its response to the recent tragic events was open and thorough.

"This can only serve to improve the care of patients."