In his report, published in March 2023, the Parliamentary and Health Service Ombudsman, notes that “Expectant and new parents are being failed right across the country, and very often in the same ways. The fact that we are still seeing the same mistakes over and over again shows that lessons are not being learned.” He adds that maternity services have received more policy recommendations than any other area of healthcare but that they have singularly failed in their purpose of reform. This rather depressing conclusion was mirrored in the also recently published independent investigation carried out by Dr Bill Kirkup (who also chaired the Morecombe Bay investigation) into neonatal deaths at East Kent Hospitals University Trust. In it, Dr Kirkup deliberately chose not to ‘identify detailed changes of policy’ as to do so ‘does not work in preventing the recurrence of remarkably similar sets of problems in other places.’
Failure to learn from past experience
Maternity units seem to be uniquely unable to learn from past experience. The CQC’s 2022 review of maternity services observes that the standard of care provided by maternity units has deteriorated in the last five years, with almost 40% providing substandard care. When something goes badly awry in industry causing death or injury, a Health & Safety investigation takes place, recommendations are made and implemented, and a penalty imposed (usually monetary) to reinforce the requirement to change practices. In the most egregious cases, a charge of corporate manslaughter can be brought. But when something similar happens in a maternity unit, an investigation is launched, recommendations made and then - nothing. Over the past few years there has been no shortage of maternity units under scrutiny, of which East Kent is the latest (with Nottingham University Hospitals NHS Trust, currently under review by Donna Ockenden, likely to be next on the list).
East Kent: a catalogue of failings
East Kent’s catalogue of failings is extensive. Their maternity services went into special measures when rated inadequate by the CQC in 2014; a Royal College of Obstetricians and Gynaecologists (RCOG) safety review made 21 recommendations in 2016; the Health and Safety Investigations Board raised concerns in 2018; the coroner at an inquest into a baby’s death described it as ‘totally avoidable’; Dr Kirkup’s investigation kicked off in 2020; and finally, the most recent CQC report (May 2023) has rated the hospital's maternity services inadequate. Reading this list, it’s not surprising that Dr Kirkup concluded that any recommendation he made was likely to fall onto stony ground. Instead, he has chosen to highlight four areas he considers should be the focus for action: identifying poorly performing units; giving care with compassion and kindness; teamworking with a common purpose; and responding to challenge with honesty. He also comments on the purpose of measuring outcomes in maternity units. Rather than being used ‘to generate meaningless league tables’, ‘risk-sensitive’ outcome measures can be developed (as has been done in other specialties) to spot ‘outliers’ before any serious harm occurs.
Persistent parents campaign for change
Reading what went wrong at East Kent feels rather like an echo. Similar failings were recorded at Morecombe Bay and at Shrewsbury, and all the individual cases highlighted by the Ombudsman reflected similar issues occurring again and again at different hospitals across the country. Poor communication between staff, and between staff and patients; lack of respect between different teams; midwives and obstetricians competing against each other; ideology-driven decisions; staff shortages; a refusal to admit shortcomings or mistakes; and inadequate management. The list goes on. In many cases, it has only been through the dogged campaigning of parents, whose babies either died or suffered irreparable damage, that has revealed the extent of the problems affecting maternity units.
Cultural problems run deep
Funding is obviously an issue and one that is closely bound up with staffing problems. But the cultural issue goes much deeper. It's not difficult to find forum threads where student and junior midwives post comments about how unsupported - and actively undermined - they have been by their more experienced colleagues (who have obviously forgotten that they were students once). There is no obvious answer to the problem: many solutions have been proposed but not implemented. Let’s see if Dr Kirkup’s suggested approach gains traction.
Having acted on behalf of families affected by their treatment in various maternity units, I would be happy to chat through the options open to you if you have any concerns about the standard of maternity care you have received.
