By John Tingle
As the year 2020 closes and another year starts, it is important to reflect on significant patient safety events and trends in the National Health Service (NHS) in England.
To anticipate what might happen in 2021, we need to recognize what may be continuing patient safety issues.
Failures of maternity care services have presented an acute patient safety issue in 2020 in some parts of England. Media reports of these failures raise several issues on topics including informed consent, communication with patients, clinical attitudes, competence, and what we might consider maternity care politics, which is characterized by an undue focus on natural birth and low C section rates.
For the Independent, Shaun Lintern reports that government ministers “have been told they must ‘stamp out’ a ‘normal’ birth ideology in NHS maternity services that puts babies and mothers’ lives at risk.”
The State of Care
Every year the Care Quality Commission (CQC), the independent regulator of health and social care in England publishes its annual assessment.
The CQC stated that maternity services are a great cause of concern, with at least one in four core maternity services rated by the CQC as requiring improvement overall as of March 31, 2020. The report describes the issues as follows:
“Looking across both ‘maternity’ and the older ‘maternity and gynaecology’ services, 41% were rated as requires improvement for safety and 1% were rated as inadequate for safety. We continued to see some services where staff did not have the right skills or knowledge, where poor working relationships between obstetricians, midwives and neonatologists posed a barrier to safe care, and where there was limited oversight of risk and a lack of investigation and learning when things go wrong.”
Maternity Patient Safety Crisis Events
Against the general maternity patient safety and care quality backdrop, 2020 saw several media reports on care quality issues among maternity patients. These reports highlighted issues with services provided by maternity care units in Shrewsbury and Telford, East Kent and Basildon, among others.
Shrewsbury and Telford
The biggest maternity crisis to ever happen in the history of the NHS is currently being investigated at Shrewsbury and Telford hospitals. An independent interim review, the Ockenden report, has just reported and found serious failings in maternity care. The review looked into the first 250 cases of a total of 1,862 set for review.
The report states that one of the most concerning aspects of the care provided at Shrewsbury and Telford is the “reported lack of kindness and compassion” from maternity health care workers there. One example cited is a letter sent to a patient that read, “If you would like to come and have a chat with me about the death of your baby,” but did not include any expression of condolences.
Other examples include:
“A woman was in agony but told that it was ‘nothing’; staff were dismissive and made her feel ‘pathetic’. This was further compounded by the obstetrician using flippant and abrupt language and calling her ‘lazy’ at one point.”
“A woman was in great pain after delivery and left screaming for hours before it was identified that there were problems that needed intervention. The attitude of some of the midwives also made the situation worse.”
The report goes into several other concerning issues including:
- incomplete or faulty risk assessment of intended place of birth
- failure to provide competent clinical care
- failure to properly manage labor
- instances of traumatic birth
- refusal to provide caesarean sections
- and failure to provide adequate bereavement care
The report offers several recommendations to improve maternity care and reduce adverse outcomes.
Also stated in the report are immediate and essential actions to improve care and safety in maternity services across the NHS. One such action involves informed consent:
“All maternity services must ensure the provision to women of accurate and contemporaneous evidence-based information as per national guidance. This must include all aspects of maternity care throughout the antenatal, intrapartum and postnatal periods of care.
Women must be enabled to participate equally in all decision-making processes and to make informed choices about their care.
Women’s choices following a shared and informed decision-making process must be respected.”
Failure to Learn from Past Patient Safety Incidents
The report provides another valuable wake-up call on maternity care safety and quality. However, poor maternity care practices have been identified before, most notably in the Morecambe Bay maternity scandal in 1995. Patient safety and care quality lessons in maternity care have seemingly gone unlearned once again.
The Ockenden report acknowledges that in the past there has been a mixed approach to implementing change from national safety reports and reviews into maternity services.
Though reports into patient safety crises have been published and recommendations have been made, systemic change has not occurred, and acute problems persist. This trend is not unique to maternity services reports, and can be seen across several NHS care areas.
Taking a holistic overview of patient safety over the past two decades, history shows that the NHS has not done a good job of learning the lessons from past adverse patient safety events and changing practices.
