The Health Secretary, Jeremy Hunt, is about to announce a change in law that will allow parents of full-term babies who are stillborn to have the death investigated by a Coroner at an inquest. The intention is for lessons to be learned from any mistakes made during labour.
In addition to this, maternity incidents will also be investigated by the Healthcare Safety Investigation Branch (HSIB) which was set up in April 2017 to review medical cases where potentially avoidable injury or death has been caused to patients.
Any steps towards learning lessons and sharing knowledge across Trusts must be applauded but I am sceptical about the remit of the HSIB whose panel includes experts from air and marine safety investigation. It seems to me to be geared towards looking at system failures rather than individual errors.
According to government statistics, the NHS treats more than one million people every 36 hours, yet the HSIB is limited to investigating a maximum of 30 incidents per year and only those arising in England from 1 April 2017 onwards. None of their current investigations relate to maternity care.
The developments in inquests and safety investigation are welcome but they are dealing with the events after something has already gone wrong. How long will it take for any lessons learned to filter through to Trusts and staff via panel members and reports, and at what expense?
We do not need a healthcare safety investigation panel to tell us what we already know: there is a fundamental shortage of midwives and a lack of investment in training.
We know that the majority of errors in maternity care relate to misinterpretation of the CTG trace which monitors the baby’s heart rate and gives warnings signs that the baby is in danger.
Trusts need to be given the funds to ensure that existing staff have access to the best equipment and training available. The mother and baby charity Baby Lifeline is ready and waiting to provide the life-saving training to staff if only they could all be given the support, time and funding to attend.
Gill Edwards is a senior clinical negligence solicitor with Potter Rees Dolan and is a member of the Multi-Professional Advisory Panel of the mother and baby charity Baby Lifeline. Should you have any queries about clinical negligence issues, in particular birth injuries, and wish to speak with Gill or any other member of the team please contact us on 0161 237 5888.