Having a baby is an exciting time, but it’s also an incredibly scary one. Over the last decade, medical negligence during pregnancy, birth, and after-birth has left over 1,200 newborn babies permanently brain-damaged, has caused over 1,300 deaths, and resulted in over 1,000 serious incidents.
This is why the Health and Social Care Committee (HSCC) published a report that gave the government 15 recommendations on how to improve the quality of the NHS maternity services in the UK.
Following on from our previous article, where we outlined 4 out of the 15 recommendations, this article will look at the HSCC’s next 7 recommendations and outline how the government has responded to each one.
These 7 recommendations look at learning from Patient Safety Incidents
- Recommendation 5: The Health and Safety Investigation Branch (HSIB) should collaborate during investigations and complete them quicker
HSIB investigates all incidents that happen before, during, and after birth, so it can give recommendations and guidance to prevent similar incidents from happening again and help families understand what happened and what will change going forward.
But the turnaround time for these investigations has often taken over six months to complete. This has resulted in a massive backlog and has meant that maternity units have struggled to implement improvements quickly.
Plus, historically, the HSIB only worked with senior staff members to conduct their investigations, so vital information from those working on the frontline during an incident was often lost or misinterpreted.
Whilst the government has accepted this recommendation in part, there are no timescales for making these improvements and there is little evidence that these investigations will be quicker.
And whilst HSIB have changed their investigation processes, cleared the backlog of investigations and reduced the investigation time to 4 months, 90% of the final investigation reports are still taking 6 months to complete.
More needs to be done to speed up the HSIB’s investigation reporting process and implementing the key learnings from incidents to prevent women, their babies suffering the same mistakes. We know that putting in place measures to stop the same thing happening to others is something our clients often speak about.
- Recommendation 6: HSIB should make the key learnings from their investigations more accessible to the wider NHS maternity network so future incidents can be avoided
How can NHS maternity units be expected to improve their maternity services if they don’t know what lessons and improvements have been taken from incidents that have happened in other maternity units?
Quite simply, they can’t!
This is why the HSCC want the HSIB to improve how they share their investigation findings with the entire NHS maternity network.
The government accept this recommendation and they’ve have made a step towards making this happen: HSIB are now regularly attending regional perinatal quality meetings. They share their findings with the key people within each regional maternity network, such as chief midwives, Local Maternity System (LMS) partners, and Care Quality Commission representatives.
But there’s still a long way to go.
Over this past year, HSIB has gathered data from over 1,700 investigations.
But they haven’t shared this information with anyone yet.
Because each individual Trust has been gathering their own set of incident data.
So, HSIB has decided to work with academic partners to pool all the data and produce a consolidated dataset that can be shared with the public and within the NHS to truly ‘’support the improvement of the maternity service”.
Let’s hope that this process doesn’t take long as this data is vitally important to maternity units making improvements.
- Recommendation 7: NHS England and Improvement (NHSEI) should streamline their data collection processes so data gaps can be eliminated and service quality standardised
HSCC has suggested that NHSEI should streamline its data collection processes so that:
- Data can be shared between maternity units efficiently and effectively
- Any gaps in data can be filled automatically
- The quality of the NHS maternity services can be standardised
NHSEI is building a portal that will be a central hub of information that can be accessed by all NHS maternity units. This portal will hold incident data submitted by each maternity unit, making it quicker and easier for them to run reports and find improvements.
But, there’s a problem.
For the portal to be effective, the data submitted must be in the same format and contain the right type of information. But the systems used by these maternity units to collect and submit data are not the same. This means that in some cases, the data being submitted is missing vital pieces of information meaning the portal is ineffective as it stands.
There is talk of a £52 million project between NHSEI and NHSX (NHS Digital) to standardise all NHS IT systems, but when that will be and how long this will take, we don’t know.
- Recommendation 8: The government should implement the Rapid Redress and Resolution (RRR) scheme ASAP to provide key learnings and support suffering families
RRR was first brought to the table in 2017. It was a compensation scheme designed to:
- Support families if their child suffered brain-damaged because of a medical mistake, and
- Help maternity professionals learn from past incidents.
But the government has rejected this recommendation. They believe that several of the benefits covered in the proposed RRR scheme have already been delivered through other initiatives like the NHS Resolution’s Early Notification scheme and the HSIB’s Independent Maternity Safety Investigations, for instance.
And they also felt that the RRR scheme didn’t address the high and rising costs of clinical negligence either. The problem is that many hospitals won’t accept the conclusions made by the HSIB following their investigations and refuse to address some of the core issues they’ve raised. This leads to ongoing courtroom battles and expensive trials. If these hospitals would just collaborate with the NHS Resolution (NHSR - formerly The NHS Litigation Authority) and attend bulk Joint Settlement Meetings (JSM’s), this would lead to early settlement agreements and a drop in costly clinical negligence cases. This would then free up money that could be put to better use to improve the quality of the NHS’s maternity services.
- Recommendations 9 & 10: The government shouldn’t make sufferers prove medical negligence to get compensated and compensation should be based on the national average wage
HSCC want the government to give families compensation based on whether the incident could have been avoided, rather than making them prove that it was medical negligence. This makes the whole compensation process easier and less intrusive for the families who are suffering.
They also feel that the amount of compensation paid should be based on the national average wage to stop any unjust compensation payouts. This is an odd statement to make because all compensation payments are supported by evidence that’s been heavily scrutinised by NHS lawyers and the courts. Plus, paying compensation based on the national average wage will only end up under-compensating the families that earn more than the national average wage. We can only achieve justice if everyone is treated fairly.
The government have confirmed that, to address the rising costs of medical negligence claims, they will publish a consultation around how compensation is awarded and how much. Next steps will be taken following this.
- Recommendation 11: The government should review regulators to stop blame culture and allow health professionals to admit their mistakes
The General Medical Council (GMC) has reported that the number of cases brought to a tribunal as a result of clinical mistakes is low, and it’s getting lower. This is because there’s a growing blame culture that’s spreading through the entire health sector. This toxic, finger-pointing type of environment is largely fostered by the NHS regulatory bodies: The Nursing and Midwifery Council (NMC) and the GMC.
Their customary accusatory approach is stopping people from owning up to their mistakes, which means that others within the NHS are at risk of repeating them.
So, the HSCC wants the government to review how their professional regulators are perceived within the maternity sector and address the fear that medical professionals have around admitting to their mistakes.
The government knows that the NMC and the GMC, have a crucial part to play in stopping the blame culture and creating a trusting environment that enables healthcare professionals to freely acknowledge their mistakes.
The GMC has delivered over 400 sessions on how healthcare workers within the maternity sector can raise concerns over a patient’s safety without feeling victimised or blamed. And they’ve also commissioned 3 reports which demonstrate the importance of moving away from a blame culture, into one that prioritises learning through mistakes.
Alongside this, the NMC has conducted some research to understand how healthcare professionals view them as regulators, with the idea being to improve how they engage and communicate with them.
The Department of Health and Social Care (DHSC) has also been working with the NMC and GMC to make changes to the legislation surrounding healthcare regulatory practices. The changes they’re proposing include:
- Providing greater discretion around determining which complaints should be investigated
- Removing the need for formal panel or tribunal hearings
- Not allowing the GMC to appeal the decisions made by the Medical Practitioners Tribunal
Let’s hope that these changes go through and that the rigid, theoretical approaches that the GMC and NMC have adopted to solve such a sensitive issue, work.
But there’s more...
We hope that the government continues its commitment to improving the NHS maternity services through learning. Although a lot of the recommendations made by the HSCC were only partially accepted by the government, there does seem to be a plan in place to improve.
Hopefully, this plan is executed sooner rather than later to keep mothers and their babies safe from medical mistakes.
Our next article which will outline the remaining 4 recommendations from the HSCC on how to improve the safety of our maternity services, here in the UK.
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