The safety of maternity services in England Contents

---

Summary

At its best the NHS offers some of the safest maternal and neonatal outcomes in the world and England is making good progress towards halving the rate of stillbirths and neonatal deaths by 2025.1 However, there remains worrying variation in the quality of maternity care which means that the safe delivery of a healthy baby is not experienced by all mothers.

Since shocking failures were uncovered at the University Hospitals of Morecambe Bay NHS Foundation Trust there has been a concerted effort to improve the safety of maternity services in England. However, major concerns have since been raised at the Shrewsbury and Telford Hospital NHS Trust and East Kent Hospitals University NHS Foundation Trust. There can be no complacency when it comes to improving the safety of maternity services and it is imperative that lessons are learnt from patient safety incidents.

Throughout our inquiry we have considered a range of issues related to the safety of maternity services in England. This report addresses the following issues:

• Supporting maternity services and staff to deliver safe maternity care
• Learning from patient safety incidents
• Providing safe and personalised care for all mothers and babies

In Chapter 1, we consider one of the essential building blocks of safe care–safe staffing and funding. We were concerned to hear that 8 out of 10 midwives reported that they did not believe that there were enough staff on their shift to be able to provide a safe service and every unit has rota gaps for doctors.2 Appropriate staffing levels are a prerequisite for safe care. We recommend, as a matter of urgency, that the Government commits to funding the maternity workforce at the level required to deliver safe care to all mothers and their babies.

After a patient safety incident, too often families are not provided with the appropriate, timely and compassionate support they deserve. We heard from Darren Smith that after the tragic loss of his son, Baby Issac, he “just wanted an apology” and “to make sure that it did not happen to other people”. Instead he faced a “battle” which was “nothing about improving the situation”.3 In Chapter 2, we explore how our current approach to patient safety incidents is resulting in rising clinical negligence costs without sufficient learning and perpetuating a culture of blame. We urge the Government to reform the clinical negligence system in a way that better meets the needs of families and establishes a less adversarial process which instead promotes learning.

In Chapter 3, we explore what women want and need from their maternity care. As we heard from Michelle Hemmington, whose son, Baby Louie, tragically died following mistakes in her care during labour, the central aim of maternity services must be to achieve “a safe, healthy, positive experience of birth and to come home with a baby”.4 Personalised care must go hand in hand with safety. We urge NHS England and Improvement to ensure every woman is fully informed about the risks of all their birthing options as well as the pain relief options that are available to them during labour.

In Chapter 3, we also explore inequalities in maternal and neonatal outcomes. Despite disparities being well documented for many years there has been little progress in closing the gap. We recognise that the underlying causes for this go beyond maternity care. However, we ask that the Government as a whole introduce a target with a clear timeframe to address the disparity.

At the same time our independent Expert Panel has conducted thorough analysis of the Government’s progress in achieving its own maternity safety goals. The overall rating across all commitments is assessed as ‘Requires Improvement’ with ‘Good’ ratings for progress on key maternity safety goals, particularly reducing neonatal deaths and stillbirths but ‘Inadequate’ ratings for aspects of continuity of carer, personalised care, and safe staffing.5