People with an interest in patient safety read the interim Ockenden report with despair. It was immediately and starkly apparent that it repeated many of the common themes which have emerged in other patient safety investigations. Further, as the report comments, ‘important recommendations from previous national maternity reviews […] have either not been implemented or the implementation has failed to create the intended effect of improving maternity care. From this review of 250 cases we can confirm that we have identified missed opportunities to learn in order to prevent serious harm to mothers and babies.’
One problem with investigations into single units is that it is psychologically easiest for clinicians elsewhere to distance themselves from the mistakes. To say, ‘It wouldn’t happen here’ or ‘That’s not my specialty.’ The harder and braver thing is to ask: ‘What can we learn?’
Moreover, with many of the recommendations in the Ockenden report already covered by national guidance, it is important to ask why the guidance wasn’t followed and whether it might not be being followed elsewhere.
The problems in Shrewsbury must not be seen to be unique. It is too often that I speak with families who have been treated appallingly by Trusts after they have experienced harm. Some of these are families who have lost healthy babies, babies who should have survived childbirth. The harm will not have been intentional but the lessons from elsewhere haven’t been learned fast enough for the families.
For me, the most devastating piece of coverage after the Ockenden report was released was a joint interview with the parents of Kate Stanton Davies and Pippa Griffiths. Seeing Rhiannon Davies’ distress that a lack of learning after Kate died had led to Pippa’s death. Witnessing one family’s guilt over another family’s grief is one of the hardest things I have ever watched.
As a lay person, I have noticed how tribal medicine can be as a whole. Competition occurs every which way. Between Trusts. Between specialties. Clinicians of all sorts can be dismissive of others. It is almost a sport and a great deal is said with humour. However, it is patients who have most to lose. An alleged drive to keep the caesarean section rate at Shrewsbury lower than the national average had disastrous results for patients. It seems nobody involved stopped to consider whether conflating caesarean section rate with good maternity care might be harmful. More broadly, organisations’ determination to protect their reputations hobbles the ability to listen and to learn.
Patients also lose if the multidisciplinary team isn’t working as a whole. The intention to work with the entire team needs to be genuine. It needs to be borne out every day. It needs to include training together. No matter what sort of birth a mother thought she wanted beforehand, she will be grateful to have a team working together for her and her baby’s safety.
The multidisciplinary team is not just midwives and obstetricians, it includes obstetric anaesthetists too. The Ockenden report highlights multiple incidents where there was delay before involving obstetric anaesthetists, and comments obstetric anaesthetists were not completely integrated into the maternity multidisciplinary team. The OAA recognise there are other maternity units where the inclusion of anaesthetists as part of the multidisciplinary team is not the default position.
In response to discussions about hierarchy in medicine, I often hear the comment that the hierarchy can never be flattened because someone needs to be in charge. An entirely fair point, but how they lead is critical. There is a need for inclusive leadership where, regardless of their expertise, leaders are comfortable seeking others’ views before acting. The benefits are two-fold: improving the quality of decision making and creating a dynamic where people feel comfortable to make suggestions. As David Bodanis writes in ‘The Art of Fairness,’ ‘When your underlings aren’t terrified of you, and you’re modest enough to know you’re fallible, you can set up channels that will help you avoid fixation.’
Crucially, the necessity to listen to others includes listening to patients. A consistent theme in patient safety investigation reports is the failure to listen to patients at the time when things go wrong and a further failure to listen in the aftermath of error.
At its most simple, listening builds rapport and showing a patient this respect helps earn their trust. But, without listening, clinicians lose a vital source of information, whether from the patient themselves or their family. Hearing what is said, and how, contributes to clinicians’ situational awareness. It may alert them to check something.
A caregiver’s failure to listen greatly compounds patients’ negative experience when things go wrong. Moreover, patients and their families often blame themselves for not getting heard. This is especially heartbreaking to hear in the most devastating cases. Listening is key for patient safety.
Over the last decade there have been so many patient safety investigations: in every case, patients struggled to get their concerns heard. The sheer scale of the ongoing investigation at Shrewsbury, involving 1,862 families over 20 years, demonstrates how dangerous it can be to not listen to patients. The tragedy is that the organisation did not hear what patients wanted more than anything else: for others not to experience similar harm.
There is so much good in the NHS. There are so many people who are committed to good, safe care despite all the challenges they face. There is excellence in maternity care and we should be learning from what goes well. But we cannot afford to dissociate from anything and everything which challenges the perception of the overall good that is done.
The concerns raised by patients about care at Shrewsbury are now being heard. A unit in Shropshire may seem far removed from clinicians working elsewhere, but we need to understand how things could go so wrong and to ask what we can learn.
We can’t change the past, but we can change how things will go from here. We must make learning better. It is not about blame. It is about accountability, kindness and compassion. All things which are good for clinicians too.
More immediately, there is one thing we need everyone in maternity care to do today and every day: to listen to mothers and to believe them.
Nobody wants the heartbreak to continue.
Susanna Stanford
