A patient safety crisis in NHS maternity care?

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In this blogpost, John Tingle discusses issues relating to maternity care in England

John Tingle

All is not well with NHS maternity care services in England. There have been several high-profile maternity crises which has resulted in the death of mothers and babies. There have been independent review investigations into some of these cases and the findings make for disturbing reading. Findings which strike at the core of NHS care delivery showing a stark violation of patients’ rights, autonomy, and safety. Confidence in our NHS maternity services can be seen to have been severely shaken by these crises.

In reviewing these crises, it is important to identify common themes, commonalities and to ask what these say about patient safety in maternity and in other care areas in the NHS. We will look firstly at the general context of NHS patient safety to set essential context for the discussion.

The NHS as a national treasure

Many in society will see the NHS rightly as a national treasure. Generally free health care delivered based on need is rightly to be valued. Health care costs countries money and is expensive However it is an important imperative that all care that is provided in any health care system will be of good and safe quality. A point made by the OECD, World Bank, and the WHO in their publication, ‘Delivering quality health services’:

“But universal health coverage should not be discussed and planned, let alone implemented, without a focus on quality. It is essential to ensure that care is effective, safe, and in keeping with the preference and needs of the people and communities being served. (p.16)”

Behind the popular NHS image

Behind the popular image of the NHS as being a national treasure there are currently immense patient safety and health quality issues which have been well documented in the national media. The most prolific example in recent times was the Mid Staffordshire Crises, ‘Francis Report’. Terrible basic care failings were revealed in the first inquiry from patients and their families which included:

-Patients were left in excrement in soiled bed clothes for lengthy periods.

-Assistance was not provided with feeding for patients who could not eat without help.

 -Water was left out of reach.

– In spite of persistent requests for help, patients were not assisted in their toileting.

-Wards and toilet facilities were left in a filthy condition.

-Privacy and dignity, even in death, were denied.

-Triage in A&E was undertaken by untrained staff.

-Staff treated patients and those close to them with what appeared to be callous indifference. (p.13).

There have been several other high profile patient safety crises which I have  discussed in my blog contributions for the Petrie Flom Centre at Harvard Law School.

The Francis Report did lead to a rethinking of patient safety in the NHS and some progress has been made towards developing an NHS patient safety culture. ‘The NHS Patient Safety Strategy’ holds out a lot of promise for systemic improvement and change.

However, history has not served the NHS well in terms of staff learning the lessons from past adverse health care events and errors are stubbornly repeated and lessons can go unlearnt. Never Events for example, operating on the patient or limb sadly happens on an all too frequent basis in the NHS. The CQC (Care Quality Commission) state in their seminal report on Never Events ,’Opening the door to change’:

“What sets Never Events apart is that they are believed to be wholly preventable by the implementation of the appropriate safety protocols. Despite this preventability, the number of Never Events has not fallen. About 500 times each year we are not preventing the preventable (p3)

Also, many would argue that the NHS  does maintain a defensive attitude when errors are made. The House of Commons Committee on Public Accounts  in their report,’Managing the costs of clinical negligence in hospital trusts’ stated:

“Despite longstanding concerns about these predictable rising costs, the government has been disappointingly slow and complacent in its response. There seems to be a prevailing attitude of defensiveness in the NHS when things go wrong, and a reluctance to admit mistakes, which is likely to be leading to more clinical negligence claims.(p.3)

Common themes

It is possible to identify several common and worrying patient safety themes in the NHS. Controversially, the NHS can be said to manifest a general defensive attitude when adverse patient safety care events occur, this is well documented in the literature. The NHS can be seen to be generally poor at learning lessons from past adverse health care events and in changing practices.

NHS maternity care scandals

Suzanne White from Leigh Day solicitors in her blog discusses maternity safety scandals across the NHS  and asks whether lessons have been learned?. She discusses several maternity scandals which include:

-London North West University Healthcare NHS Trust – Northwick Park Hospital

-University Hospitals of Morecambe Bay NHS Foundation Trust

-Shrewsbury and Telford Hospital NHS Trust

-Wales Cwm Taf maternity services

-East Kent Hospitals University NHS Foundation Trust

-Nottingham University NHS Trust.

White also references the Parliamentary Health and Social Care Committee Maternity Safety Inquiry.

Parliamentary investigation

Jeremy Hunt, the former Secretary of State for Health and Social Care is Chair of the House of Commons, Health and Social Care Committee. They recently published their Inquiry report into ,’The safety of maternity services in England’ and stated:

“There also remains worrying variation in the quality of maternity care which means

that the safe delivery of a healthy baby is not experienced by all mothers. (p.5)

The report made important recommendations for change and improvement. It shined a spotlight on NHS maternity care. The report also was critical on our current tort based clinical negligence system:

“It is clear to us that in its current form the clinical negligence process is failing to

meet its objectives for both families and the healthcare system. Too often families are

not provided with the appropriate, timely and compassionate support they deserve. (p.54)

The most recent NHS maternity care patient safety crises report’

The most recent NHS patient safety crises report on maternity care is the,’ Ockenden  report’. ,’Findings, conclusions and essential actions from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust.Our final report’:

BBC News greeted the report with the banner headline:

“Shrewsbury maternity scandal: Repeated failures led to deaths, Catastrophic failures at an NHS trust may have led to the deaths of more than 200 babies, nine mothers and left other infants with life-changing injuries.”

The report does not make for easy reading and sadly shows our NHS at its worst. There is a catalogue of major patient safety failings which should never have happened in a modern-day NHS.

Compounding concerns

Unfortunately this is not new ground for the NHS to be on.There are several common failings with the Morecambe Bay maternity crises in 2015, ‘the  Kirkup report’.


Perhaps it is possible to argue, without being too alarmist, that we have a patient safety epidemic in the NHS? We certainly have major problems in NHS maternity care.Yes, the NHS has made what I would term steady, incremental progress in developing a patient safety culture in the NHS but much more needs to be done.

We also must accept that some degree of error is going to be inevitable in health care as it is so dependent on human interaction and we all make mistakes, nobody is infallible.

However, history has not served the NHS well regarding patient safety and there are crises on an all too regular basis. The NHS must learn for the patient safety errors of the past and sadly is it stubbornly resistant to doing in places as can be seen in the reports of investigations. It must work more strongly towards developing a patient safety culture that is centred around the patient.





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