The startling rise in the cost to the NHS in England of medical negligence cases, and a sharp increase in birth injuries to mothers, are the latest warning signs of deeply troubling failures in maternity services. The £60bn estimate of negligence liabilities, from the National Audit Office, represents a quadrupling in less than 20 years. While some medical specialties have seen falling payouts, those in obstetrics rose. The reason why payments in such negligence cases are so high is that when babies are injured, awards must cover lifetime care needs.
Grave shortcomings in maternity care are widely recognised, along with unjust disparities in outcomes for women from different socioeconomic and racial groups. Preventable deaths and injuries at units in Morecambe Bay, Shrewsbury and Telford, and East Kent, have been among the most shocking patient safety scandals of recent years.
Investigations following these and other tragedies revealed a range of problems including poor collaboration between clinicians, weak leadership, a lack of openness and inability to learn from mistakes, inadequate staffing, and bad practice including a lack of monitoring. Yet despite long lists of recommendations, and some improvements including in the use of data, it is impossible to be confident that past mistakes could not be repeated. Two years ago the Care Quality Commission rated two-thirds of maternity units inadequate or requiring improvement. Last year, the first parliamentary report about birth trauma suffered by women concluded that “poor care is all‑too-frequently tolerated as normal, and women are treated as an inconvenience”.
The health secretary, Wes Streeting, has said that raising standards will be a litmus test for this government. But while his emphasis is welcome, and should prompt trust bosses to pay closer attention to an area that is too often overlooked, it is unclear how improvement will be achieved. A set of targets agreed in 2015, including halving maternal and neonatal deaths, is on course to be missed. And bereaved families have strongly criticised the remit of the rapid investigation of specific units announced by Mr Streeting in the summer, which is due to deliver its report next year.
The rising number of severe vaginal tears, as well as the increase in maternal mortality, and the level of readmissions to hospital of new mothers, all point to issues that go far beyond the relatively small number of cases in which a baby suffers brain damage as a result of medical mistakes.
In relation to maternal injuries, part of the recorded increase may be due to better reporting and greater awareness about a subject that barely used to be discussed at all. The changing demographic of mothers, with more older and heavier women giving birth, is said by experts to be one factor increasing risk. The rising proportion of caesarean section deliveries presents challenges not because they are a problem in themselves, but because they make different demands on staff and the system. It is well known that unmanageable workloads cause problems with staff retention.
Given all this complexity, there can be no simple formula for upgrading the maternity care system. The concern is that this latest review could produce yet another set of recommendations that are no more likely to succeed than others before them. But it is, at least, an opportunity to focus minds on the urgent need to improve birth outcomes and experiences.
