Calls for a national review of maternity care are quite rightly being made in light of the ‘serious and shocking’ failings exposed at a UK hospital, leading to the avoidable deaths of 11 babies and a mother.
An investigation into Morecambe Bay NHS Foundation Trust found a ‘lethal mix’ of 20 major failures in care from 2004 to 2013 at Furness General Hospital in Cumbria.
Dr Bill Kirkup, a former senior Department of Health official, who carried out the inquiry, not only strongly criticised the hospital, but also the overall NHS for the way it has monitored and regulated the major problems over a seven year period.
He says there was ‘significant organisational failure’ from the Care Quality Commission – the independent regulator of all health and social care services in England – leading to the Department of Health being ‘reliant on misleadingly optimistic assessments from regulators’.
Dr Kirkup also criticised The North West Health Authority and the Parliamentary and Health Services Ombudsman for failing to take opportunities to bring the problems to light sooner.
In summary, he said there had been a “simultaneous failure of a great many systems at almost every level, from labour ward to the headquarters of national bodies”.
So, whilst some in maternity services may well try and suggest this is an isolated incident, this is clearly not the case.
Yes, there are many excellent maternity services and thousands of dedicated midwives across the country, who at times work miracles to ensure mothers and their babies come through difficult labours safely and successfully.
However, this case has highlighted very clear failings for action to be taken when things are going badly wrong, leading to the avoidable loss of life.
The organisations and departments responsible for upholding and maintaining high standards of care – and holding failing hospitals and services to account – are simply not doing their jobs.
Despite these failures at Furness General starting in 2004, and including a cluster of five major incidents in 2008, it was only in 2011 that the issues came to wider attention. Even then it was not through dedicated care quality organisations and bodies, but after strong criticism from a coroner following the death of new-born Joshua Titcombe.
He said midwives had repeatedly missed opportunities to spot and treat a serious infection, leading to the greater scrutiny of the hospital.
Another failing identified in Dr Kirkup’s report was poor working relationships and communication between doctors and midwives.
As specialists in medical negligence, we at Neil Hudgell Solicitors handle cases involving death in childbirth and babies sadly being delivered stillborn.
In many cases it is the failure to communicate – the most basic of requirements for quality care – which causes mistakes to be made.
I recently secured compensation for a client whose baby was sadly delivered stillborn after failings in her care. Despite experiencing reduced movements from her baby on numerous occasions during the final month of her pregnancy, and suffering a haemorrhage, she was still wrongly treated as ‘low-risk’ on the labour ward, mainly due to poor medical notes and a lack of communication at the hospital.
The hospital admitted her baby would have been saved had she been induced following the haemorrhage, and the mother, who was 18 at the time, felt midwives were dismissive of her concerns throughout her pregnancy.
This was something also felt by another client of our firm, who also lost her baby when doctors and midwives failed to check her blood results, which had been taken after the patient had haemorrhaged badly.
The hospital said the blood results had not been checked due to a ‘medical emergency’ on the ward, but admitted that had action been taken quicker in terms of performing an emergency caesarean section, the baby could have been saved.
Both cases highlight basic, avoidable failings, and a need for lessons to be learned.
Dr Kirkup makes 44 recommendations, including calling for a national review of maternity care and for the General Medical Council and
Nursing and Midwifery Council (NMC) to investigate the staff involved in care during the period, following his inquiry.
This sad case must be used to bring about major improvements nationally to maternity services – and the scrutiny they come under.