In this week’s blog, our CEO discusses Maternal Deaths
In 2017 the UK ranked 26th for rates of maternal death across all Countries, aligning us approximately with Germany, North Macedonia, Slovenia and Turkmenistan. Loss is always very sad, but there is something about deaths during pregnancy and labour that creates particularly intense sadness. Most probably because we can all empathise with the vulnerability of giving birth and the loss of all the life possibilities a baby should enjoy.
We have had a number of ‘scandals’ in recent years (feels an inappropriate word for the tragedy of deaths by negligence, but that’s what the media calls them) related to hospitals with high numbers of preventable baby deaths. The East Kent NHS Foundation Trust is currently under independent review following an inquest into the avoidable death of a baby due to delays in resuscitation. The Trust had initially advised the number of avoidable deaths as 6 or 7 but then revealed that there were actually up to 15. It was found the hospital had even failed to complete the 21 recommendations of a safety review in 2016. We can only imagine the pain these families feel, knowing that the loved ones they lost could have been saved if the hospital hadn’t failed them.
In 2019 the Shrewsbury and Telford NHS Trust investigation found 95 incidents of avoidable harm between 1979 and 2017 – 50 incidents of brain damage, deaths of 3 mothers and 42 baby deaths. In 2015 the investigation into Morecambe Bay Trust found 11 baby deaths and the death of one mother between 2004 and 2013.
There are threads that tie all of these failures together – lack of challenge, covering up incompetence, out of date guidelines and a cavalier attitude to the lives of the people being supported (notably, referring to a baby as ‘it’ following their death). Unions identify a key reason as lack of staffing which creates inconsistency and a reliance on staff whose competence can be questioned, even as we take steps to massively reduce our access to a larger EU workforce.
In many cases the opportunities for failings to be addressed were dismissed to save face, to prevent bad publicity and to protect staff. In 2008, five serious incidents in one year in Morecambe led a consultant obstetrician to raise a formal complaint. It was ignored. Safety audits and inspections took place, all gave guidance and points to improve. They were buried or only partially followed.
How many of these deaths and brain injuries could have been prevented if someone had prioritised the wellbeing of these mothers and babies? High death rates had been spotted (all maternity units across the UK are monitored) but responses were left in the hands of Hospital Directors who failed to act.
There is a government initiative, started in 2015, with a goal to halve stillbirths, baby deaths and brain injuries with a current target of 2025. The Healthcare Safety Investigations Branch has been tasked to provide oversight and challenge in the cases of avoidable harm, ensuring this isn’t left in the hands of hospital directors who are obviously not up to the challenge. We can only wait to see the success of this initiative.