It was a privilege to attend the recent National Maternity Safety Conference in Birmingham and hear from so many leading experts and professionals who are passionate about ensuring the very best levels of safety for mothers and babies in the UK.
The conference, organised and hosted by mother and baby charity Baby Lifeline, is held each year to bring people together and share learning and best practice, as well as highlighting the biggest issues currently faced on wards across the country.
Of all speakers heard, it was a group of bereaved parents who have campaigned tirelessly for more openness, accountability and honesty from NHS Trusts when things go wrong who provided the strongest messages to take away.
Derek Richford, Kayleigh Griffiths and Dr Jack Hawkins and his wife Sarah have all suffered the loss of babies in their families due to negligent care – and each told how they faced outright denials initially from the Trusts involved when they began to ask questions.
When Derek’s grandson Harry died at just seven days old, his family were told there was no need for a Coroner’s involvement or an inquest and it was only Derek’s determination to get answers which lead to an inquest which found seven gross failings amounting to negligence.
This ultimately paved the way for a full inquiry to be launched into maternity services at East Kent Hospitals Trust, which will examine maternity and neonatal services in the period since 2009
Each of the families said all they had ever wanted was openness over what happened, and admissions as to where things had gone wrong, to ensure lessons were learned and that other families would not suffer in the same way.
“Denial is the biggest thief of learning” was Derek’s message – and one which Dame Ruth May, Chief Nursing Officer for England – who apologised to all the families for what they had been though – said would stay with her forever.
It was a message which certainly stuck a chord with me too, given that in our work supporting families who suffer as a result of birth negligence, we find all too often that they have faced a wall of denials, and it is only through our legal work that details of how things went wrong begin to emerge and be admitted.
We try to help get an explanation to help families understand what has happened to their baby, as often, at a time when mothers and families are at their most vulnerable, they are given an investigation report or an explanation which they probably can’t process.
It is important they take time to reflect and consider what is being said to them, and ask for advice.
If Derek hadn’t been so thorough in his review of the report he was given he would have just accepted it and never known the truth.
Credit goes to Baby Lifeline for putting these families at the very heart of this conference, as on a day when we heard plenty about the need to change and improve, they were living proof of the harm and devastation caused, and the need for complete transparency and accountability.
It was so brave of them to speak as they did, but as was said by many on the day, it should never be the case that families have to step forward and fight, they should be given answers and full explanations as a matter of course, helping all to understand, accept and learn from what went wrong.
Speakers highlighted need for accountability, equality and care with compassion
In a programme packed with excellent speakers, there were many constant themes.
The increasing pressures on staff due to high numbers of midwives leaving the profession, and the need to share best practice and learnings across the NHS, were highlighted by many.
The need for Independent Reviews – of which there have been many in recent years and two presently ongoing – to be properly acted upon was also stressed..
With an acceptance that some costly investigations and reports may have in the past ‘sat to gather dust on shelves, Donna Ockenden, chair of the recent Independent Investigation into Maternity Services at Shrewsbury and Telford NHS Trust – stressed that recommendations were no longer enough.
She highlighted how her report had been very clear in making 15 Immediate and Essential Actions which needed to be taken, each of which were fully endorsed and accepted by the Government.
It was certainly encouraging to hear examples from the maternity team at Stockport NHS Foundation Trust as to how they’d achieved a significant reduction in babies being admitted to their neonatal intensive care unit by reviewing details of admissions, providing training and implementing a new multi-disciplinary approach to CTG interpretation.
It was an example of how quite simple, achievable changes – at no significant cost – can make a positive difference to outcomes.
A powerful presentation by Sandra Igwe, Founder of The Motherhood Group, which supports black maternal experience, saw her outline the shocking statistics that black women are five times and Asian women two times more likely to die in the perinatal period than white women.
She detailed how an inquiry into racial injustice and human rights in UK maternity care found ‘systemic racism’, with women saying they had felt ‘dehumanised’ and ‘disbelieved’ on maternity wards.
She outlined a truly unacceptable situation and said both Trusts and individual staff had to tackle it by committing to becoming anti-racist organisations, and making black and brown women ‘decision makers’ in their maternity systems.
Finally, keynote speaker Michael West CBE, a Professor of Organisational Psychology, highlighted the need for a compassionate culture – particularly within a busy, demanding maternity ward given the thousands upon thousands of ‘burnt out’ midwives currently leaving the NHS.
He highlighted how compassionate care has been proven to improve outcomes for patients in studies, and how compassionate management, where staff are listened to over their worries and difficulties, understood, and helped to improve, leads to better collective workforces, as opposed to ‘command and control’ leadership.
A phrase repeatedly used throughout the day was that ‘progress has been made, but there is still plenty to do’, but events such as this, where so many can learn together, can only help speed up that process, and hopefully bring better results for mothers and babies quicker.
