England’s shameful maternity scandal
When Sarah Hawkins started having contractions, the midwives at Nottingham City Hospital repeatedly turned her away, saying she was not yet in labour. Six days later, Sarah arrived at the hospital to give birth, only to be told that her baby, Harriet, was already dead. An independent review would later discover that Harriet’s death in April 2016 was “almost certainly preventable” and occurred due to gross negligence, from “lack of midwifery leadership”, “inadequate processes to support communication of clinical information,” “lack of governance in relation to reporting serious clinical incidents” to a “poor safety culture.”
Lamentably, Harriet’s death was not an outlier, and it transpired that 13 catastrophic failures had occurred before she was delivered stillborn. Six years on, and a lack of staff, training and oversight still plague maternity services countrywide. At the end of March, the 234-page review on Shrewsbury and Telford NHS Trust by senior midwife Donna Ockenden was published, exposing one of the biggest scandals in NHS history. She included a litany of failures, including a staggering 1,592 clinical incidents from 2000-2019. It gravely revealed that 201 babies – including 131 stillbirths and 70 neonatal deaths – and nine mothers had died due to “repeated failures over two decades”, with many others left with life-long conditions resulting from their care.
More deplorable revelations have since come to light. The Times reported on Monday that even after years of raising concerns about preventable deaths resulting from poor care, babies’ and mothers’ lives are still at risk as maternity units fail to meet the basic safety standards.
It found that of the 193 NHS maternity services in England, 80 – which equates to 41 per cent – are rated by the Care Quality Commission (CQC) as “inadequate” or “requires improvement”, which means they fail to meet basic safety standards. While eight have been stamped with the lowest rating, only two maternity services – 1 per cent of the total – are rated “outstanding” by the CQC.
The health regulator retorted: “Over time we have strengthened and improved the way we inspect maternity services, and when we returned to [Shrewsbury] Trust in 2018 we took enforcement action to protect women using its maternity services, rated the trust inadequate and placed it into special measures.”
But it is precisely the lack of improvement at these trusts where failures have been recorded that is of the utmost concern. For example, Morecambe Bay NHS Foundation Trust is included among the eight hospitals given the lowest “inadequate” rating by the CQC. The hospital, which was the topic of an investigation spearheaded by Dr Bill Kirkup, was responsible for a “lethal mix” of failings in 2015 which led to the death of 11 babies and one mother.
Kirkup’s report recommended several changes for “urgent action” but last year CQC’s report on Morecombe Bay discovered failures in maternity care, including women who had been at risk of sepsis and not given antibiotics in time. Furthermore, there were not enough midwives to “keep women safe from avoidable harm.”
Last week, another report on Sheffield Teaching Hospitals added to concerns that aspects of the unsafe care found by Ockenden are rife. Hospital inspectors found that mothers are being denied adequate pain relief, food and water, with the service rated “inadequate.”
Similarly, the maternity services at Nottingham University Hospital NHS Trust are still woefully “inadequate” since Harriet’s family, and others raised alarm years ago. Despite calling for a public inquiry into maternity care, dozens of babies have now died or suffered brain damage. Although NHS England has issued a review, aggravated families – of which there are 461 alleged failings in care – have rightly stated that progress is moving with the “viscosity of treacle.”
Harriet’s father, Dr Jack Hawkins, used to “feel guilty” that her death had not led to improvements and believed that a full investigation could have saved other lives. “Just before Harriet was born, the CQC visited and rated Nottingham as good,” he said. “They failed in their duty to recognise problems in maternity care. We later found that Nottingham were failing to investigate serious incidents before Harriet died. We had to fight to discover the truth about why Harriet died […] it is not fair that it falls to bereaved families.”
On Wednesday, 100 mothers wrote to Sajid Javid demanding the appointment of Donna Ockenden to lead a review of Nottingham as she did into the maternity scandal at Shrewsbury and Telford Hospital NHS Trust. The senior midwife said she was “honoured” to be asked to do by affected families.
As Ockenden touched in on her report on Shrewsbury and Telford Hospital NHS Trust, we need systemic change to stop the toxic culture permeating our hospitals if we are to stop another maternity scandal. One place to start is to tackle the staffing crisis to relieve the pressure on midwives working arduous shifts. A recent report by the health and social care committee in parliament noted that eight out of ten midwives had reported that they did not have enough staff on their shifts to provide safe service. Another place to start is maternity budgets, which should be ring-fenced in every maternity unit to ensure high-quality training and care.
Another, is to put a stop to this calamitous obsession with “natural births” and to listen to the patient. Ockenden’s report exposed an insidious influence in the health service of a movement that favours “natural” births over modern obstetric science. The review was left with the impression that there was a “culture” to keep Caesarean sections low because it was perceived as the essence of good maternity care, even if it was at odds with the health of mothers and babies.
As Ockenden noted: “Ineffective monitoring of foetal growth and a culture of reluctance to perform caesarean sections in many babies dying during birth or shortly after their birth. In many cases, mother and babies were left with life-long conditions as a result of their care and treatment.”
With all this in mind, the picture painted of maternity care in England is a bleak one. Across the healthcare service, there undoubtedly needs to be a seismic shift in the provision of maternity care. Staff shortages need to be tackled, training needs to be improved, and there needs to be a concerted effort – internally and externally – to learn from the clinical incidents of the past so we can protect the lives of the future. Only then, will this stain on the nation’s healthcare have the chance to be a watershed moment for the safety of mothers and their babies.