‘Blame culture’ in maternity safety failures prevents lessons being learnt, says Committee
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Government’s overall progress in achieving key commitments in
maternity services ‘requires improvement’ finds Expert Panel A
wide-ranging report by the Health and Social Care Committee on
maternity safety in England finds that improvements in maternity
services have been too slow, with the CQC’s Chief Inspector of
Hospitals reporting evidence of a ‘defensive culture’,
‘dysfunctional teams’ and ‘safety lessons not learned’. Professor
Ted Baker told...Request free trial
A wide-ranging report by the Health and Social Care Committee on maternity safety in England finds that improvements in maternity services have been too slow, with the CQC’s Chief Inspector of Hospitals reporting evidence of a ‘defensive culture’, ‘dysfunctional teams’ and ‘safety lessons not learned’. Professor Ted Baker told the inquiry that more than a third of CQC ratings for maternity services identified requirements to improve safety, larger than in any other specialty. MPs recommend urgent action to address staffing shortfalls in maternity services, with staffing numbers identified as the first and foremost essential building block in providing safe care. The Committee is also publishing a report it commissioned from an Expert Panel it set up to evaluate Government progress on delivering four commitments on maternity services. It concluded that the Government’s overall progress to achieve key commitments in maternity services ‘requires improvement’. Further CQC-style ratings are awarded individually against progress in the four key areas: maternity safety; continuity of carer; personalised care; and safe staffing. Health and Social Care Committee Chair Rt Hon Jeremy Hunt said: “Although the majority of NHS births are totally safe, failings in maternity services can have a devastating outcome for the families involved. Despite a number of high-profile incidents, improvements in maternity safety are still not happening quickly enough. Although the NHS deserves credit for reducing baby deaths and stillbirths significantly, around 1,000 more babies would live every year if our maternity services were as safe as Sweden. “Our biggest concerns were around staffing and culture: staffing levels have now started to improve but we found a persisting ‘culture of blame’ when things go wrong which not only prevents people admitting that mistakes were made, but crucially, prevents anyone learning from them. “Our independent expert panel gave an overall verdict of ‘requires improvement’ which sends a strong message that the Government and the NHS need to redouble their efforts ahead of the Ockenden report into Shrewsbury and Telford and the Kirkup report into East Kent. Nothing less is owed to the families for whom a birth was not the joyous occasion they had the right to expect.” ENDS Health and Social Care Committee’s Report’s key conclusions and recommendations:
A full list of conclusions and recommendations can be found in the attached embargoed Committee Report on the Safety of Maternity Services in England The Committee’s Report pays tribute to parents and maternity service users who gave powerful testimonies to the inquiry and whose experiences were the sharp reminder that not all births were the joyous occasions a family had expected. Must be ‘no complacency’ on improving safety The Committee’s Report found that though progress to improve maternity safety had been made with a 30% reduction in neonatal deaths over the past ten years, the improvement had come from a low base. Chief Inspector of Hospitals at the CQC, Professor Ted Baker, reported that maternity services were "not improving fast enough" with elements identified in the failings at the University Hospitals of Morecambe Bay NHS Foundation Trust still found in maternity services today. Major concerns at Shrewsbury and Telford Hospital NHS Trust and East Kent Hospitals University NHS Foundation Trust were a stark reminder that lessons still need to be learned and there can be ‘no complacency’ when it comes to improving the safety of maternity services, say MPs. Midwives: ‘not enough staff’ to deliver a safe service Funding is identified as a critical factor in the delivery of safe staffing levels. Maternity services face an estimated 1,932 shortage of midwives, while 8 out of 10 members in a recent Royal College of Midwives’ survey did not believe there were enough staff on shift to provide a safe service. In a private roundtable meeting with clinicians, the Committee was told even when a unit appeared on paper to be fully staffed, sickness and attrition rates meant the reality was very different. The Report finds that in obstetrics, as a minimum, a further 496 consultants are needed. Ending blame culture MPs call for a shift in the mechanism for awarding compensation, currently based on proving gross clinical negligence, which the Committee has found perpetuates a culture of apportioning blame. In 2019–20, NHS Resolution paid out £2.3 billion in compensation and associated costs for maternity claims, representing 40% of all claim payments.Maternity incidents remain the single highest cost of claims against the NHS in England. The Committee’s Report recommends reform of litigation after finding the current adversarial system promotes a ‘culture of blame’ which prevents lessons being learnt when things go wrong. Instead a compensation award would be based on whether an incident was avoidable. The Committee heard evidence that in Sweden, which introduced a no-blame compensation scheme based on whether an incident was considered avoidable, serious avoidable birth injuries had dropped by 50%. ‘Unacceptable’ inequalities in outcomes The Committee’s Report flags the Expert Panel’s finding that the Government's commitment to halve the rate of stillbirths, neonatal deaths, brain injuries and maternal deaths was not achieving equitable outcomes, with women and babies from minority ethnic and socio-economically deprived backgrounds at greater risk when compared to their white or less deprived peers. MPs urged the Government to introduce a target to end the disparity in maternal and neonatal outcomes with a clear timeframe for achieving this goal. Expert Panel: Government’s overall progress to achieve key commitments in maternity services ‘requires improvement’ The Expert Panel and its evaluation was commissioned by the Health and Social Care Committee, with maternity services as the first area of the Panel’s work. The CQC-style ratings give independent and objective evaluation of ministerial pledges, enhancing the Committee's core task of holding Government to account. The Expert Panel’s Report is published alongside that of the Committee. It analyses Government progress against four key targets. One finding that underpins all is that none of the other commitments can be achieved without ensuring that maternity services have the right number of staff, in the right place, at the right time and with the right skills. Professor Dame Jane Dacre, Chair of the Health and Social Care Committee’s Expert Panel, said: “This is the first evaluation of its kind, commissioned by the Health and Social Care Committee and carried out independently by a panel of experts. Using a CQC-style scoring system, we have rated the Government’s overall progress on its maternity services’ targets as ‘requires improvement’. “Our Expert Panel report covers in greater detail how far the Government’s maternity commitments have been achieved in key areas. Three commitments have been rated as ‘requires improvement’ – maternity safety, continuity of carer, and safe staffing – while a rating of ‘inadequate’ has been given to the commitment to provide all women with a personalised care and support plan. “We’ve also found persistent health inequalities experienced by women and babies from disadvantaged groups, with poorer outcomes across all of the commitments we considered. “However, underpinning all this are workforce issues. Maternity services must have the right number of staff, in the right place, at the right time and with the right skills – without that progress will stall.” ENDS In addition to the overall CQC-style rating across all commitments, the Expert Panel awarded the following ratings on the Government’s progress against its four key commitments on maternity services in England. Each commitment was evaluated on whether it had been met overall or was on track to be met; whether it was effectively funded; whether it achieved a positive impact for service users; whether it was an appropriate commitment:
By 2025, to halve the rate of stillbirths; neonatal deaths; maternal deaths; brain injuries that occur during or soon after birth. Achieve a 20% reduction in these rates by 2020. To reduce the pre-term birth rate from 8% to 6% by 2025. Expert Panel found improvements in rates of stillbirths and neonatal deaths are good but are not shared equally among all service users. Babies from minority ethnic or socio-economically deprived backgrounds continue to be at significantly greater risk of perinatal death than their white or less deprived peers
The majority of women to benefit from the ‘continuity of carer’ model by 2021, starting with 20% of women by March 2019. By 2024, 75% of women from BAME communities and a similar percentage of women from the most deprived groups will receive continuity of care from their midwife throughout pregnancy, labour and the postnatal period. Expert Panel found it represents a major change to maternity systems and services and further support is required to ensure Trusts are enabled to successfully manage this scale of organisational change.
All women to have a personalised care and support plan by 2021 (revised target March 2022). Expert Panel found inadequate consideration of ways to mitigate potential barriers to impactful care planning and lack of clarity about how plans will be used to inform service delivery planning has resulted in Personalised Care and Support Plans becoming a potentially time-consuming tick box exercise.
Ensuring NHS providers are staffed with the appropriate number and mix of clinical professionals is vital to the delivery of quality care and in keeping patients safe from avoidable harm. Expert Panel found persistent gaps in all maternity professions remain. Current recruitment initiatives do not consider the serious problem of attrition in a demoralised and overstretched workforce and do not adequately value professional experience and wellbeing. Staffing deficits undermine the ability of Trusts to achieve improvements in all areas. (See detailed breakdown of ratings p5 of Expert Panel’s Report) Persistent health inequalities: The Expert Panel noted that throughout the evaluation, it was struck by the persistent health inequalities experienced by women and babies from disadvantaged groups. Women from minority ethnic or socio-economically deprived backgrounds continued to experience poorer outcomes across all commitments evaluated. Members of the Expert Panel The Expert Panel is chaired by Professor Dame Jane Dacre and is comprised of core members and subject specialists. All Expert Panel members have been officially appointed to Panel by the House of Commons Health and Social Care Select Committee. Chair:
Core members of the Expert Panel:
Maternity specialist members of the Expert Panel:
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