The health secretary, Jeremy Hunt, has said that the NHS in England has to improve its performance and learn better from its mistakes, to help to reduce the number of injuries and baby deaths suffered in childbirth.
It is estimated that every year there are 1,000 cases where babies die unexpectedly during childbirth or are left with severe brain injuries as a result of negligence during their birth.
There are around 700,00 births every year in the UK, and Mr Hunt said that these figures show that the NHS provides safe and proper care for most patients.
Number of midwives in England 3,000 short
He said, however, that all unexplained cases of serious harm and death are unacceptable, and that all of these cases will be independently investigated from now on. The task of reviewing these cases will fall to a team set up earlier this year known as the Healthcare Safety Investigations Branch.
Mr Hunt, when unveiling his new plans, said that he hoped that these measures would allow the NHS to learn from their mistakes, as they move forward towards their goal of halving the rate of stillbirths, brain injuries and deaths by 2025. This is five years earlier than the original date set by Mr Hunt.
Mr Hunt set this initial target in 2015 after concerns were raised that while progress was being made on reducing cases, the improvement was not moving at the same rate as other developed nations.
Mr Hunt said that for these goals to become reality, there would have to be an increase in the number of staff employed by the NHS.
An NHS-backed review of deaths during childbirth where the baby seemed healthy at the start of labour found that in 80% of these cases, an improvement in the level of care provided would have made the death avoidable.
The report, which was issued by the Healthcare Quality Improvement Partnership, found that the main issue behind these preventable deaths was staffing and a heavy workload.
Sarah Hawkins had a normal 9 months of pregnancy until she went into labour. It was during labour that she was told her child, Harriet, had died.
In the beginning, Nottingham University Hospitals Trust said that the death was due to an infection, however, Sarah and her husband Jack, who both had jobs working for the trust, demanded an external review. It was during this review that the real story became apparent.
There had been poor management and a number of fatal errors made throughout the process, something which was a direct result of the pressure being put on the services.
A maternity unit has to be closed to new admissions because of understaffing.
After she was admitted to hospital, there were a number of missed opportunities to correctly identify problems in their infancy. The staff at the hospital failed to recognise the signs that she was in active labour, as well as making mistakes when monitoring the heartbeat of the child, and most importantly did not provide a quick enough reaction when the situation became critical.
The trust eventually admitted that had these failures been addressed, Harriet would have survived. It also apologised to her parents, for the ‘unimaginable distress and sadness caused.’
Sarah said: ‘It's taken us 19 months to get an external, independent review. We've been trying to find answers for our daughter and it shouldn't be us trying to fight. It has had such a significant mental and physical impact on our mental wellbeing.’
Mr Hunt has said there was ‘not enough staff across the whole NHS’, and he would be looking to address this issue by introducing a major expansion in the coming years with training places.
Despite the plans for the major expansion, Mr Hunt has said that there are still steps that could be taken immediately to help the health service improve the way that they deal with mistakes.
He said: ‘We make it really difficult for the NHS to learn what happened and to spread the message about what needs to be done differently next time. People are worried about lawyers, regulation and being fired by their own trust. We have to change a blame culture into a learning culture.’
He said that the key to achieving this was to act quickly to make sure that the new Healthcare Safety Investigations Branch will automatically look at all the NHS cases of potentially avoidable harm.
It is currently the responsibility of local hospitals to investigate individual cases, or for parents to bring clinical negligence cases against the NHS.
Mr Hunt said that he hoped the move would allow parents to receive quick answers, and allow for learning to be shared across the NHS. He said that this shared learning would help toward reducing the total cost the NHS pays for settling clinical negligence claims for babies who are born with brain injuries.
On average, there are two cases like this settled every week in the UK, with every settlement costing the NHS millions of pounds to help provide for the lifetime care of the children.
Mr Hunt said that the government would propose changes in the law, allowing coroners to conduct investigations into full-time stillbirths, something which they are currently unable to do. Some parents have suggested that their children’s deaths have been classified at stillbirths to avoid coroner’s investigations.
Gill Walton, the general secretary for the Royal College of Midwives has welcomed the measures. She said that she found the low staffing levels ‘concerning’, and that in England, the NHS is currently short 3,000 midwives.
She said: ‘The increasing complexity of women being cared for in our maternity services exacerbates this issue. We must ensure we have enough midwives and obstetricians to provide safe care throughout the maternity pathway and adequate facilities in all birth settings.’
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