020 7650 1200

Baby Sleeping

Families need answers into baby deaths and substandard care in UK maternity units

Leigh Day Clinical Negligence Partner Suzanne White explains why the calls for a public inquiry into poor maternity care are justified and why she agrees that one is needed.

Posted on 21 July 2020

The sounds of a call for a public inquiry into incidents of poor care around childbirth in the UK are becoming increasingly louder.
Public inquiries were established under the Inquiries Act 2005 to investigate events which could or have caused public concern. They can be led by one person, often a judge or a panel, who take evidence in written and verbal representation. 
The inquiry aims to determine what happened and how to prevent it re-occurring. Its findings, produced in a concluding report, may be followed by criminal or civil action but the inquiry itself does not have the power to point to liability.
The inquiry can designate people who have been involved in the events being investigated as ‘core participants’ and as such they can be awarded funds for legal representation.
An example of a public inquiry is the Mid Staffordshire Inquiry which reported in 2013, seven years after concerns were first raised into unacceptably poor levels of patient care at Stafford Hospital.
Journalist Shaun Lintern, now health correspondent at the Independent, played a key role in escalating concerns and raising public awareness of the scandal at Stafford Hospital. Shaun's stories revealed the appalling treatment patients had suffered, were fundamental to the rising public outrage and the government’s eventual acceptance that a public inquiry should take place.
Similarly, Shaun’s stories have heightened concerns about East Kent and Shrewsbury, and more, are shining a light on the scandals and putting pressure on the NHS to face the same. 
At East Kent, maternity services are under investigation because of a series of failings which led to 15 baby deaths at the William Harvey Hospital, Ashford, and the Queen Elizabeth the Queen Mother Hospital, Margate.
At Shrewsbury, according to a BBC report, the Ockenden Review is looking at 1,000 cases stretching back to 1979, and it has now been reported that as many as 1,800 cases have been raised. It is an absolute tragedy for the families involved. The Review was set up in 2017 and its findings are expected at the end of this year. The review initially focused on 23 cases in which maternity failings were alleged.
Further, it has been announced that a criminal inquiry has been set up into maternity care at Shrewsbury and Telford NHS Trust and West Mercia Police has encouraged anyone who has information which could help them with their enquiries to make contact.
The BBC has reported that the independent inquiry lead investigator Dr Bill Kirkup has contacted affected families but would like to hear from affected families to whom he hasn’t spoken.
The call for people to make their voices heard will be welcome news to the families who have suffered the trauma of poor care at a time when, as Dover and Deal MP Natalie Elphicke told Kent Online:
"No-one should be satisfied until safety and security for mother and baby is delivered in every case.”
When healthcare scandals begin to come to light, a familiar chorus is ‘no one would believe me’; ‘they just didn’t want to know’; or more latterly: ‘at last someone is listening.”
Inquiries offer some relief that families will at last have their voices heard, that their stories will be told and that someone with the power to effect change will be listening and taking note.
The call to be heard was a refrain throughout the recently published Cumberlege Review, into the consequences of the use of Primodos, vaginal mesh and Sodium Valproate. Leigh Day represented four groups of families who had been affected by the use of the epilepsy drug Sodium Valproate in pregnancy. The result for them was that many babies were born with disabilities.
When the women affected had protested their plight, for almost 30 years they went unheard. When Baroness Julia Cumberlege published her report, with one voice the four groups expressed their gratitude that she had listened to their representations through interview and through Leigh Day lawyer Bozena Michalowska-Howells.
Like the investigations into East Kent and Shrewsbury scandals, Cumberlege was not an official public inquiry and many medical bodies declined to take part. Since the conclusions were so devastating about the way the NHS had systematically failed to listen to the patient voice, that lack of participation is already causing red faces.
The general consensus appears to be that Cumberlege listened so well and her recommendations are so precise, that a public inquiry is not necessary.
However, rising concerns about the need for yet more independent reports into maternity care, following the Morecambe Bay report five years ago, are fuelling calls for a public inquiry into standards of care on labour wards.
Former Secretary of State for Health and Social Care, Jeremy Hunt has called for such an inquiry into maternity care in the UK in light of deep concerns over baby deaths at East Kent NHS Trust and mounting fears over those at Shrewsbury and Telford.
The families need answers, accountability and change so these terrible tragedies never happen again.