In September 2021 the independent maternity services oversight panel published their most recent in-depth report providing an update on their ongoing review of the maternity and neonatal care provided by Cwm Taf Morgannwg University Health Board. This report is the much-anticipated update to the initial findings by the Royal College from April 2019 which identified significant concerns surrounding the standard of maternity services in some South Wales hospitals. We have written about this previous report here. This latest report looks at stillbirth and neonatal mortality and morbidity cases.
Previous reports have revealed shocking details of widespread and various failings. This follow up report has shown “good progress” has been made to improve on areas of failure that had been previously identified, but this is of little comfort to the families whose lives have been permanently affected. It is understandable that COVID-19 has stalled planned progression and improvement and we are so thankful to all NHS staff that have gone above and beyond the call of duty in very trying circumstances. However, the question must remain, is the NHS doing enough to prevent these errors and are they learning from their mistakes?
This current report shows that 33% of stillbirths investigated could have had a different outcome if the case had been managed differently. A further 59% of cases were found to have minor areas of improvement – things that could have been done better that may not have changed the outcome.
Only 6% of stillbirths investigated were found to have no improvement in the level of care required.
These stats are a sad indictment of the levels of medically negligent birth injuries that are occurring, but more importantly, it is sobering to realise the lack of care that women and their babies have received. It raises the question of how the level of care could be allowed to slip so far.
In 2016 the National Maternity Review published its “Better Births” report which was a plan for NHS maternity services over the following five years. It highlighted grave failings in maternity services and laid out a plan to improve the level of care provided to women, children and their families. Five years later, we are still seeing reports of failings within NHS maternity services in both England and Wales.
In 2017 the Department of Health published “A Rapid Resolution and Redress Scheme For Severe Avoidable Birth Injury: a Consultation” which stated in the introduction, “it is clear that there is still more that we can do to achieve our vision to make NHS maternity services among the safest in the world.” The consultation sought to better address how families should be compensated if they have received sub-standard care that resulted in a severe brain injury. But four years on, for many families, the only option is still to make a claim through the courts.
In the meantime, we have seen independent reviews of NHS maternity services from too many areas of the UK. From as early as 2015 an independent review found “dysfunctional” services in 5 key areas of maternity and neonatal care at Morecambe Bay. In May of 2021, the BBC uncovered a 2016 review of the maternity services at Doncaster and Bassetlaw NHS Foundation Trust that was never published. It was only one of several reports that have gone unpublished, not just in maternity services, but in other areas too.
In 2020 the Ockenden report was published detailing the birth injuries in the maternity and neonatal services at Shrewsbury & Telford Hospital NHS Trust. Recently, another independent investigation has launched looking into failings at East Kent maternity and neonatal services.
The reporting process is so important in deciding which periods of care or specific cases may need to be reviewed. If this information is absent, incomplete, or incorrect, hospitals can never know the full extent of the problems that they face. When instances go unreported, hospitals aren’t alerted to potential failings in practices, staffing or procedures and they aren’t able to make changes and improvements. The same can be said for the families who have missed the opportunity to understand their treatment and what went wrong.
In many cases, the mothers and their families are not aware of their ability to raise a complaint within the NHS complaints procedure or their rights to make a civil claim for compensation if they have been subjected to medical negligence that has led to a birth injury for either mother or baby.
Adequate reporting and the sharing of information must be paired with a way to ensure a reasonable standard of care and treatment across the NHS. Each report that comes out uncovers circumstances that were unique to the particular hospital or NHS Trust that was being reviewed, however, many of the overriding themes relate to issues of poor leadership, failure to escalate risk, poor communication between staff and patients and poor clinical judgment or decision making. These are serious systematic failings that require change at every level.
Improvements are being seen and positive changes are being made, but this is a serious and ongoing task of improvement that will require time. Importantly, a joined-up approach to improvements across all maternity services in the NHS would go a long way to ensuring that in five years’ time we don’t find ourselves in the same position we are in now. We wouldn’t want to see improvements in the hospitals currently under review while other hospitals fail to implement the lessons learned. All health boards should be praised for their hard work during these difficult and unparalleled times during COVID-19, but the fact that these maternity and neonatal reviews are frequent shows that we need to continue with this improvement and not allow any of these issues to fall to the wayside.
We welcome improvements and change when we see them in individual hospitals and NHS Trusts, but these systemic failings must be addressed across the board as a priority and monitored regularly. The ultimate goal must be to have a system in place that prevents these birth injuries and baby deaths from occurring in the first place. We must be able to reassure pregnant women across England and Wales that they and their babies will be safe when it comes time to deliver. We cannot continue to use repeated and regular retrospective reviews moving forward which address these issues after the event.
