As a leading maternity charity, Baby Lifeline has worked with maternity professionals across the country for 40 years helping to support safer maternity care. In recent years there has been a welcome focus on improving maternity care, with a number of high-level national initiatives aimed at reducing the levels of avoidable harm.
Despite this focus, Baby Lifeline believes that more action is needed to address common themes which we still see adversely affecting the safety of maternity services across the country today.
Baby Lifeline welcomes today’s announcement that the Health and Social Care Committee is opening an inquiry into maternity safety in England. The Safety of Maternity Services in England inquiry will examine evidence relating to ongoing concerns despite the substantial amount of work carried out in recent years.
- Many of the themes highlighted in high profile maternity investigations are not isolated to the individual trusts but are likely to be more widespread.
- Systemic issues relating to maternity safety need to be understood at a national level to initiate rapid change, improve patient safety, and prevent future “scandals”.
- The Care Quality Commission (CQC) inspections of maternity services have found that issues identified in the Morecambe Bay Investigation (The 2015 Kirkup Report) are still affecting maternity care today.
As one of the leading charities working to improve maternity safety, we work closely with frontline maternity professionals who strive to do their utmost to provide the safest care possible; however, it is clear that there are a number of factors within the culture and system that must change to improve patient safety and support frontline professionals better.
Repeated National Themes
We have seen certain maternity units in the news recently where poor care has been reported by hundreds of families. Leaked and published investigation reports have revealed some themes:
- A lack of appropriate or timely escalation, communication and teamwork when mums and babies need extra support.
- A coverup culture, where mistakes are not acknowledged or learned from.
- Issues with the interpretation of the fetal heartbeat.
- Failure to listen to families when they voice concerns.
Sadly, these are not unique to these trusts or indeed new. The CQC highlighted that “….the issues identified in the 2015 Kirkup report – staff not having the right skills or knowledge; poor working relationships between obstetricians, midwives and neonatologists; poor risk assessments; and failures to ensure that there is an investigation and learning from when things go wrong – are still affecting the safety of maternity care today”.
Similar identified issues can be found in the work by the Healthcare Safety Investigation Branch (HSIB), whose purpose is to improve patient safety through effective and independent investigations. And by the Royal College of Obstetricians and Gynaecologists ‘Each Baby Counts’ work, which looks at the care of babies born with severe brain injuries acquired at birth or sadly died.
What Needs to Happen?
We hope that this inquiry can look carefully at the issues we know are crucial to safe maternity care, with the aim of preventing future avoidable harm and improving patient safety.
Areas for the Investigation to Consider
- Why previous recommendations from reports investigating deaths and injuries in maternity have not yet been implemented; for example, the Morecambe Bay Investigation five years ago.
- The gaps in high-quality training to support staff in providing safe care.
- Promoting multi-professional working, communication and collaboration between different maternity professionals.
- The defensive and closed approach that seems to typify how some healthcare organisations respond to problems – this approach inhibits learning.
- The lack of standardisation in guidance and approach in key areas; for example, fetal monitoring and CTG interpretation, which are often cited as a national issue.
- How organisations investigate and learn from avoidable harm and how identified lessons are shared across the system to prevent future harm.
- What changes could be made to the civil litigation system to ensure that legal processes do not inhibit learning processes.
- Improving the quality, collection and analysis of data around maternity safety – so that significant service problems can be reliably flagged up earlier, without the need for harmed families to campaign to raise awareness major problems.
Funding for Training
Last year, Baby Lifeline joined forces with the Independent newspaper to campaign for the government to take urgent action on maternity safety – including the urgent need to provide funding to support high quality multi-professional training. This is something which is frequently included in report recommendations, and our own research has shown significant variation between trusts. The main barriers to providing this training were highlighted by the frontline to be related to staffing and funding.
Judy Ledger, CEO & Founder of Baby Lifeline supports the investigation:
“We owe it to mothers, babies and healthcare professionals to take urgent stock of where we are with maternity safety, review the actions already being taken to make progress, and take steps to address any gaps and increase the pace of change needed.
Baby Lifeline believes that there is an urgent need to better understand these issues and take action to ensure changes are made to prevent a cycle of repeated scandals. We look forward to contributing to the Health and Social Care Committee inquiry.”