Abstract
In March 2015, Dr Bill Kirkup published his report, the Morecambe Bay Investigation 1 looking at the provision of maternity care at Furness General Hospital between 2004 and 2013. The report found ‘…a lethal mix’ of failings had contributed to the deaths of 16 babies and 3 mothers.
One of these deaths was my baby son Joshua, who died on 5 November 2008. A series of serious failures following Joshua’s birth resulted in an infection that could have easily been treated with antibiotics being left until he collapsed at 24 hours of age. After nine days of fighting for his life, despite the very best efforts of the dedicated team of expert neonatal intensivists who did their utmost to save him, Joshua died at the Freeman Hospital in Newcastle.
As well as the trauma of losing Joshua, as is too often the case following serious patient safety failures, my family experienced a defensive response to what happened. Critical medical records went ‘missing’, various local investigations were less than honest and ultimately, the local trust failed to learn from what happened and more preventable deaths happened following his death.
To quote Dr Kirkup: …errors occur in every healthcare system. What is inexcusable, however, is the repeated failure to examine adverse events properly, to be open and honest with those who suffered, and to learn so as to prevent recurrence.
Changes since
In the years since the Morecambe Bay Investigation report was published, improving the safety of maternity services in England has been high on the national agenda.
In November 2015, the UK government announced a new policy ambition to halve the rate of stillbirths and infant deaths in England by 2030. 2 Since then, the target date for the ‘halve it’ ambition has been brought forward to 2025. The recently published ‘long term plan’ for the NHS3 sets out the steps being taken towards achieving this ambition. These include a new National Maternal and Neonatal Health Safety Collaborative and steps to ensure every trust that provides maternity services has a named Maternity Safety Champion.
There are positive signs that progress is being made. For example, in 2016 a new Saving Babies’ Lives Care Bundle was launched. 4 An independent evaluation 5 of the care bundle published last year found a 20% reduction in the stillbirth rate at the 19 maternity units where it was implemented, suggesting 600 lives could be saved if the same results were replicated nationally.
Version 2 of the Saving Babies’ Lives Care Bundle 6 was launched in March 2019 and for the first time, implementation of the bundle is set to be mandated for every trust in England by inclusion in the NHS contract.
In 2016, the UK government also launched a one-off £8.1m Maternity Safety Training Fund (MSTF), distributed by Health Education England to support trusts to commission high-quality multidisciplinary training. A recently published independent evaluation of the fund 7 found that over 30,000 training courses were delivered through the scheme achieving ‘…positive and sustainable learning’. However, the report warns that ‘without ongoing financial support, there is a risk that the benefits of the MSTF initiative will…diminish’.
A new approach to learning from harm
In 2018, the Royal College of Obstetricians and Gynaecologists’ Each Baby Counts programme published their second major report 8 looking at the care of term babies who were either stillborn, died shortly after birth or were at risk of brain damage in England in 2016.
The review found that 674 babies (71%) might have had a different outcome with different care. The report also highlighted the variability in the quality of the local investigations following these tragic events:
In almost a quarter of instances, parents were not involved, or even made aware of reviews taking place. Only 10% of the investigations included an external panel member and 11% of the investigations were of such poor quality that the Each Baby Counts team were unable to make a reliable judgement on the quality of care based on the information available.
As our family found out following Joshua’s death, if the response to such events is defensive and less than completely open about what happened it can increase the risk of further harm – why and what changes needed to prevent the same thing happening again are not explored. It can also have a considerable adverse impact on families and the staff involved.
In recognition of these issues, the healthcare system in England is pioneering a new approach to the way such cases are investigated.
From 1 April 2018, the Healthcare Safety Investigations Branch (HSIB), a newly established body in England with the remit to undertake system-wide investigations into patient safety events, for the sole purposes of learning (not blame), was given the remit to investigate all cases of term stillbirth, maternal deaths and cases where term babies were indicated as being at risk of hypoxic brain injury. This has been a significant programme of work involving the training of more than 140 specialist maternity investigators.
HSIB have recently announced 9 that the roll-out of this programme is now complete, meaning than from 1 April 2019, 100% of such cases will now be investigated independently via this new approach. If Joshua’s death was to happen today, instead of the agonising processes of defensive and dishonest investigations we went through, an independent investigation focusing on system factors and not individual blame would take place. If this had happened back in 2008, whilst it wouldn’t have changed the outcome for Joshua, it would undoubtably have helped prevent further similar tragedies from happening.
What more needs to be done?
The efforts to improve maternity safety in England are still in their early days. The success of HSIB’s new approach to maternity investigations will depend on how the learning from these investigations is translated into system-wide recommendations for change and how well those recommendations are implemented and embedded into practice. Success will require a joined-up approach, with all parts of the system aligned and working together to support improvement.
The importance of high-quality multi-disciplinary training to the delivery of safe maternity care is also clear, 10 yet gaps in the quality and consistency of maternity training have recently been highlighted. 11
It is essential that all maternity units have access to the funding they need to ensure all staff have access to high-quality, multi-disciplinary training to support the safest possible care for mothers and babies.
Providing these issues are addressed, the UK government’s ambition to half the rate of avoidable harm in maternity services must have a real chance of success. If the trajectory heads in this direction, perhaps it’s only a matter of time before other healthcare systems around the world follow suit with similar initiatives.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.