By John Tingle
Unfortunately, it’s never too long before a major NHS patient safety crisis hits the newspaper headlines in the United Kingdom. The Shrewsbury and Telford Hospital Trust (SATH) maternity scandal has just become a major breaking U.K. patient safety news story.
Shaun Lintern reports in The Independent:
Hundreds of families whose babies died or were seriously injured at the Shrewsbury and Telford Hospital Trust do not even know their cases have been identified for investigation in the biggest maternity scandal to ever hit the NHS… Dozens of babies and three mothers died in the trust’s maternity wards, where a ‘toxic culture’ stretched back to 1979, according to an interim report leaked to The Independent this week.
Patient Safety Scandals
These events follow closely in the footsteps of the Morecambe Bay maternity scandal where tragic avoidable harm again took place to mothers and babies. The events at Morecambe Bay were unforgivable in an NHS that prides itself on good quality care and an efficient, effective patient safety system. The Chairmen of the independent inquiry at Morecambe Bay, Dr. Bill Kirkup stated in the report in 2015:
Clinical competence was substandard, with deficient skills and knowledge; working relationships were extremely poor, particularly between different staff groups, such as obstetricians, paediatricians and midwives; there was a growing move amongst midwives to pursue normal childbirth ‘at any cost’; there were failures of risk assessment and care planning that resulted in inappropriate and unsafe care; and the response to adverse incidents was grossly deficient, with repeated failure to investigate properly and learn lessons.
Kirkup also comments in The Independent on the leaked Shrewsbury interim report and states that the lessons of Morecambe Bay were ignored in Shrewsbury and Telford. The consequences of not learning patient safety lessons were deadly in some instances in Shrewsbury and Telford as they were in Morecambe Bay.
The tip of a large iceberg?
The events at Morecambe Bay and Shrewsbury raise the specter of similar events unfolding at other hospitals in maternity care and beg the question: are Morecambe and Shrewsbury and Telford are just the tip of a large iceberg? Hopefully they will prove not to be, but we don’t know as yet.
Failure to Learn Lessons
There is a tragic human cost in the maternity scandals which words cannot convey. The events will shake public confidence in our NHS. Such events should not be happening in a mature health service which is one of world leaders in patient safety practice. Failures to learn the lessons from past adverse health events is an endemic problem in the NHS.
NHS Resolution, the NHS organization that manages clinical negligence claims for NHS hospitals is trying hard to develop schemes which effectively manage the risk in the maternity area and advance good quality care. They state some financial cost figures in this area:
Obstetric incidents can be catastrophic and life-changing, with related claims representing the scheme’s biggest area of spend. Of the clinical negligence claims notified to us in 2018/19, obstetrics claims represented ten percent (1,068) of clinical claims by number, but accounted for 50% of the total value of new claims, £2,465.5 million of the total £4,931.8 million.
The need to improve NHS maternity care goes beyond question.
The need to learn the lessons of past adverse health events in maternity care, however, does seem in practice to be much easier to state than to do as recent events show.