That some things go wrong in childbirth is a tragic reality for too many families; some deaths and life-altering injuries just cannot be avoided. Giving birth is not without risk.
But too many families are living with the torment of knowing what happened to them was entirely avoidable and, worse still, that the NHS tried to hide the truth from them, causing them to have to fight for years to get answers.
The latest revelations, over the scale of failings in maternity care at Nottingham University Hospitals NHS Trust, serve to underline the systemic failures now being revealed in maternity units across the NHS.
When even the biggest hospitals like Nottingham, once lauded for its safety and quality reputation, can sink to such depths that it starts classing the deaths of mothers as “low harm” incidents, or reporting deaths to a coroner as “expected” when they were the result of serious errors, it’s hard not to conclude there is something rotten at the heart of maternity services.
At Nottingham, whistleblowers say the trust ignored warnings about staffing levels, with a “Teflon team” of managers that allowed vacancies to double after a warning letter signed by staff was sent to the trust board.
Baby Wynter Andrews may well have been alive today if the trust had taken action to ensure midwives were not being stretched.
But staff shortages and under-pressure services only explain so much. It is clear at Nottingham and other now infamous hospitals, such as Shrewsbury and Telford Hospitals Trust and the East Kent Hospitals University Trust, that something more unpalatable was taking place.
Incidents were “swept under the carpet”, downgraded to avoid serious investigation and even when investigations were held parents like Sarah Seddon, whose son Thomas was stillborn, weren’t even involved. Reports, when they were written, were changed to lessen their severity.
This is a sign of a defensive culture that puts reputation of the service above the experiences of patients and, crucially, ignores the potential learning from mistakes to prevent them happening again.
There can be no excuse for the sorts of practices seen in some maternity units recently; as long ago as 2015 the inquiry into maternity failings at Morecambe Bay was a clear warning sign of what a toxic culture can mean for babies and mothers. That so few of the final inquiry recommendations have been acted on should shame the government and NHS England.
Nottingham University Hospitals Trust has acknowledged it has let down families and its maternity service is in need of improvement. The trust should be applauded for at least facing up to the challenge, unlike Shrewsbury, which denied the problem for so long. The sheer volume of baby deaths and injuries made it the largest maternity scandal in NHS history.
When almost 80 maternity units across England are rated as needing to improve on safety by the Care Quality Commission (CQC), we must conclude this is a system failure. In recent weeks, the CQC has downgraded four maternity units including at Sheffield Teaching Hospitals Foundation Trust and at Northwick Park Hospital, in London, where the culture was so bad staff felt bullied and were shouted at. A CQC inspector was themselves shouted at when they were confused for being a member of staff – funny if it didn’t reflect something so worrying.
NHS England has rightly, if belatedly, put its hand in its pocket to invest £96m in maternity services on an ongoing annual basis. This will help recruit more midwives and doctors and will also fund dedicated safety training for staff. This will help – although it is not yet enough to solve the problem. It’s likely the NHS needs at least three or four times as much investment according to the Royal College of Obstetricians and Gynaecologists.
It is encouraging to see many maternity staff finding their voice to whistleblow about safety to journalists and the CQC. Sunlight is the best disinfectant, and it is needed now more than ever in some of the darker recesses of NHS maternity units.
But until staff working in these departments, specifically those in senior and middle management levels, start acting with more honesty, transparency and compassion towards bereaved families, we are not going to see the improvements needed. Too many have allowed themselves to drift away from the core values of the NHS. A lot of the changes needed must start at an individual level.