The failings of former Furness General Hospital midwife Marie Ratcliffe have been laid bare nationally by her admission of making mistakes contributing to the deaths of two babies.
At a Nursing and Midwifery Council hearing, she has also accepted more than 60 additional allegations, including failing to correctly monitor mothers and babies during labour, failure to document her actions and failure to request assistance from a doctor.
These mistakes were made over a nine year period, between 2004 and 2013, and will no doubt cause many to feel anger towards her, as she was a health professional who apparently knew she was letting down her patients – both mothers and unborn babies – but continued to do so for many years.
Ms Ratcliffe has unsurprisingly apologised for her failings, insisting that she will “regret” what happened for the rest of her life. Importantly, she denied being part of any cover-up, or an effort to “conceal the truth”.
It would perhaps be unfair to doubt the honesty of those statements. It is certainly hard to believe any member of the health service would make such errors – two of which have contributed to the deaths of babies – and not feel huge regret and guilt.
However, Ms Ratcliffe also chose to use the hearing to highlight how the systems within the maternity services she worked for had been inadequate, and that she was governed by those procedures.
It follows an investigation into Morecambe Bay NHS Foundation Trust, which runs the hospital, recently concluding that there had been a ‘lethal mix’ of 20 major failures in care from 2004 to 2013 at the Cumbrian hospital.
“I hope that the recently published Kirkup report into Morecambe Bay maternity services may have begun the long-delayed process of closure for the families affected and I feel it is important not to delay that further by defending myself against these charges,” said Ratcliffe in a letter read out.
“I recognise that those monitoring, supervisory and regulatory systems have subsequently been found to be inadequate and flawed, but I was subject to them as they were then. I had no control over them, nor did I have control over the way in which they were implemented or the individuals who chose to implement them in the way that they did.”
Whilst many may consider such a statement to be excuse making, it is worth highlighting that the issues in cases such as this usually go much deeper than one individual failing in their duty of care. The finger of blame can rarely, if ever, be pointed at one individual – or even a number of health workers who have made grave errors.
As specialists in handling cases of medical negligence, we at Neil Hudgell Solicitors represent many women who suffer from substandard care during their pregnancies. We know there are many excellent maternity services and thousands of dedicated midwives across the country, who at times work miracles to ensure mothers and their babies come through difficult labours safely and successfully.
Many of these dedicated people will make mistakes at times, as it is a high pressure job where instinct and quick reactions are often required.
However, when these mistakes are made, it is vital that they are honestly and openly admitted and assessed.
The circumstances and contributory factors need to be understood, and lessons must always be learned as part of an ever-improving culture of improvement – not blame.
In the cases we handle, the pressures of a busy or understaffed department, or a lack of appropriate communication between departments, often lead to these errors. These are errors that more often than not, could have been avoided.
We believe our work is holding health organisations and departments responsible when failing to maintain high standards of care, are when they have simply failed in their jobs. Failing to learn from mistakes, and allowing them to go on, unchallenged, for so many years, will only lead to more lives being lost in the years to come.