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Genuine recognition of failures is essential for maternity care to improve

Claire White, clinical negligence solicitor based in Leigh Day's Manchester office, discusses the recent report on maternity services at North Manchester General and Royal Oldham Hospitals

Pregnant woman
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Claire is a medical negligence solicitor based in Leigh Day's Manchester office.  You can follow Claire on twitter on @clairewhite336
An internal report into maternity care at the Pennine Acute Hospitals NHS Trust has identified appalling treatment of mothers and babies at North Manchester General and Royal Oldham Hospitals, some of which led to avoidable deaths and other long term health problems which should have been prevented.

The report links bad attitude and a lack of compassion to deaths and harm, and states that there was an “embedded culture of not responding to the needs of vulnerable women”.

The Review of Maternity Services was prepared by Divisional Director at the trust, Deborah Carter, and was put to the trust’s Board in June 2016, but has only now come into the public domain.

The Executive Summary states that at North Manchester General Hospital “there has been clear evidence of poor decision making which has resulted in significant harm to women” and that issues relating to the management of women in labour, particularly in relation to the monitoring of babies’ heart rates, “has resulted in high levels of harm for babies in particular, which has a significant life long impact”. 

How are these systemic failures demonstrated in individual cases?

Some examples from the report of how individual mothers and babies have been harmed by these failings include:
  • “Following surgery a woman was taken back to theatre three times but no effective resolution achieved or the diagnosis of faecal peritonitis made, the woman remained in hospital for several months and now has a colostomy.”
  • "A baby girl died following birth because the mother was not identified during her antenatal care as being rhesus negative and given the appropriate treatment to prevent any adverse effects on her baby.”
  • In another case, a woman suffered from a “catastrophic haemorrhage” and died due to a “failure to respond to [her] deterioration over a period of days”. Staff put her symptoms down to mental health problems. The report states that “staff did not build the effective clinical picture from her presenting vital signs and laboratory results, they preferred to focus on the fact that she was demonstrating bizarre behaviour, rather than understand its cause”.
  • In perhaps the most shocking case highlighted the report states: “A woman gave birth to her baby just before the legal age of viability (22 weeks and 6 days), whilst no resuscitation would be offered to an infant of this gestation, compassionate care is essential. However, when the baby was born alive and went on to live for almost two hours, the staff members involved in the care did not find a quiet place to sit with her to nurse her as she died but instead placed her in a Moses basket and left her in the sluice room to die alone.”
  • Both hospital sites are above average for reporting severe perineal trauma (third and fourth degree tears).

Why has this happened?

The CQC has raised concerns about the high reliance on locum medical staff (34%) and commented that leadership in the service was deficient.

The report highlights that concerns have also been raised about the midwifery workforce in relation to posts which have not been recruited, recent resignations, and the high sickness absence rate.

Criticism is made that certain skill sets and competencies are lacking at the trust, and the report also highlights issues with there being “not enough staff” and “poor staff attitude”.

The individual cases noted are not isolated incidents and the report states that “further examples of this are spread over a number of years and in the recent months, demonstrating an enduring culture”.

What can be done?

The report makes many recommendations; the most fundamental of those being that “the Board need to consider additional funding of midwifery posts”. Strengthening of leadership and a review of the consultant workforce so that reliance on locums is removed are also noted to be required.

As a general principle, however, the first barrier to be overcome when looking at an organisation’s ability to improve is to ensure that there is a genuine recognition of failings in the first place. 

Media reports that the trust did not want the report to come into the public domain are concerning because the more open any dialogue is surrounding these failings, the greater the prospect of those failings being addressed properly.

The issues surrounding the publication of the report highlight a tension between the Duty of Candour – a legal duty on hospitals to inform and apologise to patients if there have been mistakes in their care that have led to significant harm - and the proposed “Safe Space” principle, which espouses protections to clinicians and staff so that they can talk freely about what has gone wrong without fear of reprisals.

It would be tragic if the tension between these two principles prevented The Pennine Acute Hospitals NHS Trust from making the sweeping changes that are required to ensure that they can provide a safe environment for mothers and babies in the future.

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