Too many English hospitals risk repeating maternity scandals involving avoidable baby deaths and brain injury because staff are too frightened to raise concerns, the chief inspector of hospitals has warned.
Speaking at the opening session of an inquiry into the safety of maternity units by the health select committee, Prof Ted Baker, chief inspector of hospitals for the Care Quality Commission, said: “There are too many cases when tragedy strikes because services are not not doing their job well enough.”
Baker admitted that 38% of such services were deemed to require improvement for patient safety and some could get even worse. “There is a significant number of services that are not achieving the level of safety they should,” he said.
He said many NHS maternity units were in danger of repeating fatal mistakes made at what became the University Hospitals of Morecambe Bay NHS foundation trust (UHMBT), despite a high profile 2015 report finding that a “lethal mix” of failings at almost every level led to the unnecessary deaths of one mother and 11 babies.
“Five years on from Morecombe Bay we have still not learned all the lessons,” Baker said. “[The] Morecombe Bay [report] did talk about about dysfunctional teams and midwives and obstetricians not working effectively together, and poor investigations without learning taking place. And I think those elements are what we are still finding in other services.”
Baker urged hospital managers to encourage staff to whistleblow about problems without fear of recrimination. He said: “The reason why people are frightened to raise concerns is because of the culture in the units in which they work. A healthy culture would mean that people routinely raise concerns. But raising concerns is regarded as being a difficult member of the team.”
His remarks come as more than 2,000 cases of potentially avoidable baby deaths, stillbirths and brain damage are being investigated at a number of hospital trusts. The majority occurred at Shrewsbury and Telford hospital NHS trust since 2000, but an investigation has also begun into 40 similar cases in East Kent hospitals trust and into 150 cases at two maternity units in south Wales.
Baker called for an end to the blame culture in the NHS. He said: “Defensiveness leads to services not being transparent, not sharing, not admitting when things are going wrong, and not being willing to apologise and recognise they’ve got something wrong.”
He added: “It’s easier to blame someone than to accept that is a systematic problem. So anything that drives defensiveness and blame is dangerous for services and goes against providing safe care. We need to do everything to try and eradicate blame from the system.”
Dr Bill Kirkup, who led the investigation into serious failings at Morecambe Bay, told the MPs that cutting a £8.1m national maternity safety training fund in 2017 cost lives and brain injuries.
He told the committee: “The training was withdrawn after a year and that was disappointing, because there was evidence accumulating was that it was effective. If it is as effective as it was looking at that point, it would certainly have had a net negative cost in terms of the birth injuries and litigation as well as the human loss that we’ve avoided.”
Kirkup, who is currently leading the review into East Kent, said some maternity units had tried to “actively conceal” failings.
He added: “When they get in sufficient trouble, their response is to stop communicating with the outside world and to disguise the failings. I think they do that with intention that they can sort it all out themselves before they have to tell anybody. But it’s quite difficult to get past that barrier.”