The investigation into care and concerns at Furness General Hospital makes sad reading and yet again details a culture of missed opportunities to identify failings in care and patient services. The report considered care provided from 2004 to 2013 and worryingly reveals a catalogue of errors mirroring those seen in the Francis Report regarding Mid Staffs.
In this trust there appears to have been a further complicating factor - a poor working relationship between midwives and obstetricians which placed mothers and babies lives at risk.
Many maternity units provide a true approach to birthing care allowing the most appropriate medical practitioner to provide care, with other professionals providing support and additional care when required. The overlap between responsibility for care or assessing the risks of a birth requires staff to use expertise, knowledge and have trust and confidence in their colleagues. It does also create additional opportunity for errors and mid-judgments to occur. The culture at Furness General Hospital allowed those risks to become a sad reality.
We have seen examples of similar circumstances in maternity care within this region, where the overlap between community midwife care, GP care and involvement of potentially two hospital teams can mean test results are missed, standard protocols fail and complications not identified and treated.
The Kirkup report into the Cumbrian hospital and Trust makes a number of Trust specific and NHS warnings:
- Clinical competence of a proportion of staff fell significantly below the standard for a safe, effective service. Essential knowledge was lacking, guidelines not followed and warning signs in pregnancy were sometimes not recognised or acted on appropriately
- Poor working relationships between midwives, obstetricians and paediatricians. There was a ‘them and us’ culture and poor communication hampered clinical care
- Midwifery care became strongly influenced by a small number of dominant midwives whose ‘over-zealous’ pursuit of natural childbirth ‘at any cost’ led at times to unsafe care
- Failures of risk assessment and care planning resulted in inappropriate and unsafe care
- There was a grossly deficient response from unit clinicians to serious incidents with repeated failure to investigate properly and learn lessons
With lessons to be learnt such as:
- Reviewing skills, training and duties of care
- Better team working
- Better risk assessment
- An audit of maternity and paediatric services
- Better joint working across sites
- Reviewing incident reporting and investigation, complaint handling and clinical leadership; and
- Improving the physical environment of the delivery suite at the hospital
With a further Francis report on whistleblowing also published on 3/3/15, attention continues to be focused on how the NHS reacts to errors and incidents, and the ability to raise concerns effectively.
Risk management and learning from complaints raised yet again, which is cold comfort for the families damaged by the mistakes in maternity care. Let's hope that since the reports of 2013, the NHS Trusts have listened and learnt avoiding more heartache for new parents, their babies, extended families and also the health care professionals involved.
If you would like to speak to someone regarding concerns you have about maternity and ante natal care, then please contact Jennie Jones on 01279 755777, or email firstname.lastname@example.org for a free and confidential initial discussion.