The publicity surrounding the alarming statistic that in one in every 5 births there are lapses that lead to mistakes is scary. Jeremy Hunt’s desire to make it his “top priority” to tackle these incidents is a step in the right direction because any mistake in maternity care can have devastating consequences.
Every single mistake or near miss needs to be scrutinised because it could have evolved into the death of mother or baby and/or baby having severe long term consequences such as Cerebral Palsy. We have spoken about this issue in a previous blog "Can the NHS reduce stillbirths and avoidable cerebral palsy cases?".
It is interesting that the NCT suggest that maternity care is “in crisis” and there is little doubt the constant financial pressure on the NHS means that services are squeezed and mistakes are more likely to happen. Jeremy Hunt is right to pledge to tackle this at a systemic level and we can only hope that with systems being brought in to aid learning and information dissemination, they will produce a decline in the numbers of these adverse events. The systems will however, have to be robust.
Unfortunately, it remains the case that accidents will happen. Even the best unit will occasionally slip up and there will be an avoidable outcome that impacts a family dramatically.
Given the duty of candour which requires organisations to tell patients what has happened, it should, in theory, be a straight forward process to identify the issues. Our experience is that the reality is sometimes that patient’s voices are not heard and parents are left in the dark, sometimes unaware of what has happened and why their situation seems to be so at odds with what they were expecting (after all childbirth should be the most joyous of events).
Jeremy Hunt’s focus on reducing the number of adverse events and near misses is positive. When things go wrong patients and their families must continue to have access to specialist help (we would argue lawyers) to help them navigate through what is often complicated medicine to help them understand their own particular circumstances.