MATE RNI T Y
Maternity safety: are lessons being learned?
An inquiry by the Health and Social Care Committee on maternity safety in England has found that improvements in maternity services have been too slow, while the CQC’s chief inspector of hospitals reported evidence of a ‘defensive culture’, ‘dysfunctional teams’ and ‘safety lessons not being learned’.
Over the past decade, there have been some high-profile investigations into failures in the maternity sector and a series of reports have made distressing reading – including stories of mothers being treated with ‘a lack of compassion’, harm being caused to babies and mothers, women being forced to give birth ‘naturally at any cost’, failures to properly monitor and identify fetal distress, and failures to learn lessons from mistakes. Some common themes have emerged from these high-profile inquiries, but what have we learned from these events and how far have we come on the road to change?
The Morecambe Bay Investigation The Morecambe Bay Investigation (published in March 2015) detailed 20 instances of significant failures of care at the Furness General Hospital (FGH) maternity unit. These were believed to have contributed to the deaths of three mothers and 16 babies.
The inquiry subsequently concluded that the maternity department at FGH was ‘dysfunctional’ with serious problems in five main areas: l Clinical competence of a proportion of staff fell significantly below the standard for a safe, effective service. Essential knowledge was lacking, guidelines were not followed and warning signs in pregnancy were sometimes not recognised or acted on appropriately.
l There were poor working relationships between midwives, obstetricians and paediatricians. There was a ‘them and us’ culture and poor communication hampered clinical care.
l Midwifery care became strongly influenced by a small number of dominant midwives whose ‘over-zealous’ pursuit of natural childbirth ‘at any cost’ led at times to unsafe care.
l Failures of risk assessment and care
planning resulted in inappropriate and unsafe care.
l There was a grossly deficient response from unit clinicians to serious incidents with repeated failure to investigate properly and learn lessons.
The report said proper investigations into serious incidents as far back as 2004 could have raised the alarm. However, it was not until five serious incidents occurred in 2008 that the reality began to emerge.1
Inquiry into the Shrewsbury and Telford Hospital NHS Trust Further concerns were raised about maternity care at the Shrewsbury and Telford Hospital NHS Trust and, in the summer of 2017, following a letter from bereaved families, the former Secretary of State for Health and Social Care, Jeremy Hunt, instructed NHS Improvement to commission a review into new-born, infant and maternal harm at the Trust. A total of 250 cases were initially reviewed and, in December 2020, an interim report was published. The final review, in late 2021, is expected to include as many as 1,862 cases. To date, a number of critical areas of concern have been identified in relation to care at the Trust – including a reluctance to conduct Caesarean sections; a tendency to blame mothers for problems; a failure to handle complex cases; a lack of consultant oversight, failure to properly monitor fetal heart rates, and a “deeply worrying lack of kindness and compassion”.2 The report described a service that lacked ‘organisational memory’ – with a very high turnover in senior leadership. The initial inquiry also highlighted a lack of preliminary investigations of serious events, as well as inefficient risk management and reporting systems, which failed to explore or address the root causes of issues.
SEPTEMBER 2021
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