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Maternity Safety: The national reaction to local tragedies

Maternity Safety: The national reaction to local tragedies

By James Titcombe

In recent months maternity safety in England has been prominently featured in the media. In November 2019, a leaked interim report by Donna Ockenden  revealed the extent of problems in maternity services at Shrewsbury and Telford.

This week has seen two significant announcements which reveal big steps being taken nationally to improve maternity safety.


Local Tragedy Promotes National Reaction

Maternity services at East Kent have been under the spotlight following the tragic death of baby Harry Richford following serious failure in his care in November 2017. An inquest into Harry’s death concluded in January and found that Harry’s death was as a result of neglect. This spotlight extended to the Houses of Parliament on the 13th February, when Nadine Dorries, Minister for Mental Health, Suicide Prevention and Patient Safety made a statement in the house of commons relating to failures in maternity care at East Kent NHS Trust.

In response to concerns raised about wider failure in care at the Trust, the government asked the Healthcare Safety Investigation Branch (HSIB) and the Care Quality Commission (CQC) to produce reports to look at safety issues within maternity services at the trust. The parliamentary statement confirmed that these reports have now been received and that “…these have identified a number of safety concerns, including the availability of skilled staff, particularly out of hours, access to neonatal resuscitation equipment, the speed with which patient concerns are escalated up to senior clinicians and obstetricians, along with failings in leadership and governance”.

The CQC have reported that a known risk to the trust is that “midwives may not be escalating in a timely way to medical staff, when fetal distress has been identified”. Other concerns raised by CQC include:

  • Operating procedures are not embedded, the risk assessing of women is not robust and correct pathways are not identified to be able to provide the necessary care and treatment.
  • Early warning scores are not calculated to assess whether scare and treatment should be escalated.
  • Instances where midwives were put in a position of where they had to make decisions on the care and treatment of high-risk women that should be been made by a doctor.
  • Incidents are not being routinely reported.

In response to the calls for an inquiry from the parents and grandparents of baby Harry, NHS England and NHS Improvement have now announced a full independent inquiry to be Chaired by our Honorary President, Dr Bill Kirkup CBE.


New National HSIB Investigation

In other important news this week, the Healthcare Safety Investigation Branch (HSIB) have announced a new national investigation looking at ‘delays to intrapartum intervention once fetal compromise is suspected.’

The national investigation was triggered after reviewing local maternity investigations HSIB has carried out so far. This review found that delays to intrapartum intervention once fetal compromise is suspected is a contributing factor to stillbirths, neonatal deaths and babies born with suspected brain injury. According to HSIB, the investigation will:

  • Draw on the field of safety science to understand how staff work within the clinical environment and how they adapt to the challenges posed by the system in which they operate. It seeks to identify factors which modify the impact of issues such as staffing, infrastructure and workload on delays to intrapartum intervention once fetal compromise is suspected.
  • Consider opportunities for building resilience into the delivery of care for labouring mothers


Calls of a Wider Inquiry into Maternity Safety

In response to concerns about maternity safety across the system, including the emerging concerns relating to Shrewsbury and Telford and East Kent, the former Secretary of State for Health and Social Care and newly appointed Chair of the Health Select Committee, Jeremy Hunt, has called for wider investigation to maternity safety.

In an article published in the Telegraph this week, Mr Hunt states that “maternity units up and down the country need extra support both in terms of staffing and training to make sure they can adopt the best practice that is common in many hospitals”.


Learning from Adverse Outcomes

Baby Lifeline welcomes the positive national reaction to learn and better understand the causal links in these cases of tragedy, and the vindication for those families left bereft and campaigning for change.

It is crucial to recognise that the types of issues that have been reported at Shrewsbury and Telford and East Kent and recently by HSIB are not isolated. There is a need to investigate the common themes that have been repeated across maternity services and highlighted in multiple reports and inquiries. It is now approaching five years since the Morecambe Bay Investigation report was published, and many of the themes highlighted by this report are relevant to recent news.

As well as learning through future investigations and inquiries, it’s also crucial that we implement the known solutions recommended in previous inquiries and reports.

Staff working in our maternity services set out to deliver the best care they can, but maternity units across the country also need support in terms of staffing and training.

Baby Lifeline have joined forces with the Independent newspaper to call for urgent action on maternity safety, including the establishment of a regular fund to support high-quality multi-professional training for all maternity staff, as well as ensuring families affected by problems in maternity care are involved in high-quality investigative processes.
“It is vital that the lessons, now plain to see are learnt and acted upon, not least by other Trusts which must not believe that it could not happen here.”  – The Kirkup Report (2015)

It is vital that recommendations from high-quality, detailed investigations and inquiries do not gather dust on shelves but are carefully and comprehensively embedded into practical changes designed to make maternity care safer.



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