Maternity safety scandals across the NHS – have any lessons been learned?
Suzanne White looks at the maternity safety scandals across the NHS and considers if any lessons have been learnt.
Posted on 17 August 2021
As a former radiographer and as someone who worked in the NHS for many years, I have a good understanding of the pressures of working in the NHS and what a wonderful job it does for patients.
But as a clinical negligence lawyer for the past 25 years I have also seen how negligent care can impact on those that have been injured, and their families.
The main reason I am instructed by families is that they want to make sure the tragedy and mistakes that happened to them never happen to anyone else.
An area of increasingly urgent concern is maternity care in England and Wales, where mistakes that have exposed horrifyingly poor practice dating back to the 1980s are still being repeated in health trusts across the country.
I have acted for many families who have suffered a tragedy because of poor or negligent maternity care. In many of the cases there are some common themes: often a mother’s concerns about her baby are not listened to; or a shortage of staff has had an impact on the care, because junior and inexperienced staff are left without supervision; other cases have highlighted the need for more consultants to deal with complex pregnancies.
There have been cases where pushing the ‘normal’ birth ideology and not giving women the ability to choose how they give birth has left women who wanted a caesarean section with terrible birth injuries, such as severe perineal tears.
When a newborn has suffered brain injuries as a result of poor maternity care which stems from poor midwifery and obstetrics training, families have to endure the further insult of a trust’s failure to learn the lessons of the tragedy.
As I said to the Independent's health correspondent Shaun Lintern, the emphasis on clinical negligence costs by ministers is back to front. The law is there to compensate people appropriately. To focus on how much that all costs once people have been injured is just the wrong way round. We will reduce the cost so much more if we have proper maternity care.
At the moment, we’ve got maternity scandals day in, day out, which are pure evidence of the fact that our maternity units are just not up to scratch. They’re unsafe for mothers, unsafe for babies, and that is not acceptable. Why is everyone consumed with the cost of the damage when the damage itself should be the first priority? What will flow from that is cases will go down and costs will reduce.
These are some of the issues that have been factors in my cases over 25 years, yet as we see below those are still factors that play out in the maternity scandals in the news.
London North West University Healthcare NHS Trust - Northwick Park Hospital
The hospital was the subject of two investigations by the Healthcare Commission over 10 maternity deaths between April 2002 and April 2005 and as a result it was put into special measures. The investigations found bad relationships between consultants and midwives, poor systems for learning lessons after things went wrong and for managing risk and a lack of leadership. It found that the maternity service was overstretched and short of equipment.
Despite this, three more women died between June 2007 and March 2008.
Then just earlier this year the hospital has once again been rated ‘inadequate’ by the Care Quality Commission after eight babies died in the space of five weeks between July and August 2020. Once again concerns about bullying have been raised. As a result of the findings, the CQC has deemed the department a "risk to patient safety".
University Hospitals of Morecambe Bay NHS Foundation Trust
The Morecambe Bay inquiry was set up in 2013 following the deaths of 11 babies and a mother at Furness Hospital in Cumbria between 2004 and 2013. The inquiry found a culture of collusion, denial and incompetence, and an insistence by midwives to pursue natural childbirth at any costs.
In August 2021 the Care Quality Commission (CQC) downgraded the NHS trust’s maternity services at Furness General Hospital to inadequate. The CQC inspector said past improvements “have not been sustained and the service has deteriorated, affecting patients and staff”.
Shrewsbury and Telford Hospital NHS Trust
In 2017 an NHS inquiry was held into more than 1,200 allegations of poor maternity care dating back to the 1970s. It found that 15 women and more than 40 babies died because of poor care at the trust, which had a culture that denied women choice.
Donna Ockenden chaired the inquiry and found that there were some cases where women were blamed for their loss, mothers were given insufficient information about their suitability for giving birth in a midwifery led centre, there was a failure to manage complex pregnancies, a failure to escalate concerns by midwives and the drive for vaginal births was pushed to keep caesarean section rates low. The inquiry found that the trust failed to investigate incidents and this led to mistakes being repeated.
Wales Cwm Taf maternity services
In April 2019 maternity services at the hospitals were put into special measures after a report by the Royal College of Obstetricians and Gynaecology was prompted by concerns raised by a consultant midwife.
The report said that maternity services at the Royal Glamorgan and Prince Charles hospitals in Llantrisant and Merthyr Tydfil may have put the lives of mothers and babies at risk as staff were under extreme pressure. It highlighted 43 potentially serious incidents between January 2016 and September 2018 including stillbirths, neonatal deaths and complications of pregnancy or delivery.
An independent panel was set up to look at the care given to 150 women in that period. In the first of three reports delivered earlier this year, the panel said dozens of women who needed emergency treatment during childbirth at the two maternity units experienced substandard care which could have been avoided.
East Kent Hospitals University NHS Foundation Trust
East Kent Hospitals University NHS Foundation Trust was fined £733,000 in June 2021 over serious failures that led to the death of a week-old baby in 2017. It was the first time the Care Quality Commission had prosecuted a trust for criminal standards of clinical care.
A review into maternity care at the East Kent NHS Trust is being led by Dr Bill Kirkup, who also led the damning inquiry into poor maternity care at University Hospitals of Morecambe Bay NHS Foundation Trust. A report published in April 2020 by the Department of Health and Social Care outlined 24 maternity investigations undertaken since July 2018, including the deaths of three babies and two mothers.
The trust has admitted it took action on only two out of 23 recommendations made by a damning 2016 review of maternity services by the Royal College of Obstetricians and Gynaecologists (RCOG).
Earlier this year it was revealed there had been dozens of deaths at East Kent Hospitals Trust with more than 130 babies suffering brain damage as a result of being starved of oxygen during their birth over a four-year period.
Nottingham University NHS Trust
A chaotic and dangerous picture of maternity care at Nottingham University NHS Trust hospitals was presented in an expose in June 2021. A joint investigation by Channel 4 and The Independent newspaper revealed that between 2010 and 2020 46 babies had suffered brain damage and 19 had been stillborn the trust maternity units.
A second story in July 2021 revealed anger and anxiety among midwifery staff who were hit by shortages of staff and vital equipment.
The report followed a CQC ‘requires improvement’ rating. Inspectors said the maternity care provider had to improve safety, effectiveness and leadership.
Parliamentary Health and Social Care Committee Maternity Safety Inquiry
In light of mounting public concern about the increasing number of maternity care scandals across the UK, Chairman of the Parliamentary Health and Social Care Committee, Jeremy Hunt, set up an inquiry into maternity care and safety in July 2020, saying: “If we had the same neonatal death rate as Sweden 1,000 fewer babies would die every year.”
Myself and my colleagues, Emmalene Bushnell and Angharad Vaughan, submitted evidence to the inquiry, telling Mr Hunt why we believe the number of clinical negligence cases in maternity care was not falling.
We said in our submission: “More needs to be done within the NHS to highlight the importance of transparency when things go wrong and to ensure learning from incidents of avoidable harm.”
This was borne out on the day the inquiry heard from Helen Vernon, Chief Executive NHS Resolution, and Dr Jenny Vaughan, Learn not Blame Policy Lead at the Doctors’ Association UK.
In her evidence, Helen Vernon referred to a £37 million settlement I had recently agreed with an NHS trust, the biggest in NHS history, to provide compensation for a child who was starved of oxygen at birth.
The committee was listening to expert input about how the NHS could move away from lengthy legal cases and instead compensate families properly within months and not several years of such tragedies.
Helen Vaughan told the panel: “We hear that people have an ingrained belief, that you should not admit liability on a case . . . because it might result in litigation. That is something we have constantly tried to debunk, to encourage candour, and it could be built far more effectively into clinical training.”
Dr Jenny Vaughan said “candour, apology and an open culture” was needed.
Initiatives to improve maternity care
Of course there have been some good initiatives to improve maternity care, such as Each Baby Counts which reports annually on critical findings and data relating to mothers and babies, to improve care and safety. Better Births is an NHS initiative which was set up to improve maternity outcomes and allow access of information for women to make decisions about their maternity care. More recently the Health and Safety Investigation Branch which is a national maternity investigation programme to make maternity care safer.
But as we can see, we still have some way to go.
The cost to the NHS
NHS Resolution reported that over 2019/20 the total cost to the NHS of clinical negligence cases was £2,323 million. In fact cases concerning poor maternity care make up approximately 40 per cent of that bill – yet those cases account for only nine per cent of the claims.
In the face of so many maternity scandals the NHS focus must be on improving care and avoiding the utter devastation for families who have to bring up a child with a brain injury.
Updated on 20 September 2021