The safety of maternity services in England Contents

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1Introduction

Providing safe maternity care for mothers and babies

1.The vast majority of NHS births in England are safe and at its best NHS care offers some of the safest maternal and neonatal outcomes in the world.6 Progress in improving maternity safety has also been impressive with a 30% reduction in neonatal deaths and 25% reduction in stillbirths over the last decade and our Expert Panel rated progress in these areas as ‘Good’.7 But the improvement has come from a low base and if we had the same rate as Sweden approximately 1,000 more babies would survive every year.8

2.There also 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. The impact of any maternity incident for a family is a tragedy but such tragedies are often made worse because key lessons are not learned, and they end up being repeated.

3.At the instigation of the Chair of the Committee, then the Health Secretary, Dr Bill Kirkup CBE led an independent review to investigate maternity safety incidents between 2004 and 2013 at the University Hospitals of Morecambe Bay NHS Foundation Trust.9

4.In 2015 the Kirkup review uncovered “serious and shocking” problems with maternity care at the University Hospitals of Morecambe Bay NHS Foundation Trust.10 The independent review catalogued “a series of failures at almost every level–from the maternity unit to those responsible for regulating and monitoring the Trust”.11 Dr Kirkup was clear that lessons must be learnt, and the investigation shone a spotlight on maternity safety.

5.Since then there has been a focus on improving the safety of maternity services in England. This includes the Royal College of Obstetricians and Gynaecologists’ (RCOG) Each Baby Counts (EBC) programme, the National Maternity Review’s clear vision for Better Births and the continuing work of the Maternity Transformation Programme (MTP). The Government remains committed to achieving the National Maternity Safety Ambition of halving stillbirths, neonatal deaths, brain injuries and maternal deaths by 2025.12 A chronology of the various programmes, initiatives and investigations is set out in Appendix 1.

6.However, since the Morecambe Bay scandal, major concerns have once again been raised, at Shrewsbury and Telford Hospital NHS Trust and East Kent Hospitals University NHS Foundation Trust. The emerging findings from investigations into those trusts are 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.

7.Professor Ted Baker, Chief Inspector of Hospitals, Care Quality Commission (CQC), told us that whilst maternity services were improving, “we still had not learned all the lessons” and that maternity services were “not improving fast enough”.13 He reflected that elements from Morecambe Bay were still to be found in maternity services today; including a defensive culture, dysfunctional teams, and poor quality investigations without learning taking place.14 During the opening session of the inquiry he told us that:

38% of our [CQC] current ratings for maternity services are that they require improvement for safety. That is a significant number, and larger than in any other specialty. It is a reflection of the cultural issues in maternity services nationally.15

8.In December 2020, Donna Ockenden released interim findings from an independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust. The review identified themes not dissimilar to Morecambe Bay. Donna Ockenden highlighted that the Immediate and Essential Actions directed at all trusts were not new and built on recommendations in previous reports. She stated that “had earlier recommendations been followed at the Shrewsbury and Telford Hospital NHS Trust some of the adverse outcomes we are investigating might not have occurred.”16

9.We recognise that the failings seen at Morecambe Bay, Shrewsbury and Telford and East Kent are not reflective of all maternity services. However, nor are they unique, reflecting many underlying problems that contribute to a poor safety culture in other parts of the system.

Patient safety culture

10.The NHS Patient Safety Strategy, launched in 2019, set out the main features of a positive patient safety culture including a compelling vision, an openness to learning, psychological safety for staff, diversity and teamwork and leadership. However, NHS England & Improvement (NHSE&I) acknowledged that “culture change cannot be mandated by strategy, but its role in determining safety cannot be ignored.”17

11.In January 2021 we held a private roundtable meeting with clinicians. At that meeting, we heard examples of a positive safety culture supporting staff in speaking openly after mistakes have been made. However, one clinician emphasised the challenge of achieving this:

It’s a really fine balance, as soon as the exec board gets sight of ‘oh there’s a dashboard’ and you know it’s red, it’s orange, it’s green, let’s put performance markers on this, and culture, teamworking is such a sensitive, personal area that as soon as you start treating it as a performance dashboard, it loses the emphasis it’s trying to make. It’s really sensitive, but it’s so important that we need to find ways of getting it right.18

We recognise that it is not easy to measure culture. But throughout this report we identify ways to ensure there is a positive culture for both clinicians, mothers and families more uniformly across a large system.

Moving forward

12.The Department of Health and Social Care (the Department) and NHSE&I have a clear vision for improving maternity services which is shared by many key stakeholders, and the recommendations generated by a focus on maternity services over recent years have been largely welcomed. However, as Professor James Walker, Clinical Director of the Maternity Investigation Programme, Healthcare Safety Investigation Branch (HSIB), aptly told us, the implementation of recommendations is the next point of failure when working towards improving patient safety.19

13.This report sets out our conclusions and recommendations in three parts:

• Chapter 1 addresses the essential building blocks of safe care - first and foremost staffing numbers and funding, underpinned by leadership and training.
• Chapter 2 focuses on learning from patient safety incidents; first we consider the role of the newly formed Healthcare Safety Investigation Branch; we then examine the current clinical negligence system and how to reform it to allow a more positive learning culture to take root.
• Chapter 3 explores women’s experience of care and considers the changes required to ensure safe care is a reality for every mother and her baby. This includes tackling unacceptable inequalities in outcomes; specific interventions to improve outcomes, including continuity of carer and screening; and finally, and most importantly, supporting informed choices and personalised care, to ensure that no woman faces pressure to have an unassisted vaginal birth.

14.We are incredibly grateful to parents and maternity service users Michelle Hemmington, Darren Smith, James Titcombe, Atinuke Awe and Clotilde Rebecca Abe for sharing their experiences with us during this inquiry. We thank them for the strength, courage, and humility they demonstrated while giving their powerful testimonies. Each account was a sharp reminder that not all births are the joyous occasion a family has patiently waited for. Improving the safety of maternity services is ultimately about protecting families from the unimaginable and life changing consequences hidden behind the statistics.

15.We also thank the clinicians who joined our roundtable. Their insights as frontline clinicians were invaluable to our inquiry and we were impressed by their passion for caring for mothers and babies.

The Committee’s Expert Panel

16.In summer 2020, as a Committee we commissioned an Independent Panel of Experts to assess the Government’s progress in meeting its own targets in key areas of healthcare policy.20 The first area we asked our Expert Panel to consider was maternity services given the large number of Government commitments made in this area. The Expert Panel conducted detailed analysis of the Government’s progress against four key objectives (Box 1).

Box 1: Expert Panel CQC-style Ratings - Overview

Overall, our Expert Panel rated the Government’s progress against four key commitments for maternity services as: Overall: Requires Improvement Commitment Rating Maternity Safety By 2025, 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 Overall: Requires Improvement Stillbirths: Good Neonatal deaths: Good Pre-term births: Requires Improvement Brain injuries: Requires Improvement Maternal deaths: Inadequate Continuity of Carer The majority of women will 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. Requires Improvement Personalised Care All women to have a Personalised Care and Support Plan (PCSP) by 2021. Inadequate Safe Staffing 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. Requires Improvement A further breakdown and summary of the Expert Panel’s findings can be found in Chapter 2 for safe staffing and Chapter 3 for maternity safety, continuity of carer and personalised care. Detailed analysis is published in the Expert Panel’s independent report: Evaluation of the Government’s progress against its policy commitments in the area of maternity services in England.21

17.We’re pleased to see that the Government is on track to meet its ambition of halving stillbirths and neonatal deaths by 2025. However, the findings from our Expert Panel clearly highlights that there is some way to go in achieving safe and personalised care for all.