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English hospitals 'have not learned lessons' of past maternity scandals


Too many English hospitals risk repeating maternity scandals involving avoidable baby deaths and brain injury because staff are too frightened to raise concerns, the chief inspector of hospitals has warned.

Speaking at the opening session of an inquiry into the safety of maternity units by the health select committee, Prof Ted Baker, chief inspector of hospitals for the Care Quality Commission, said: “There are too many cases when tragedy strikes because services are not not doing their job well enough.”

Baker admitted that 38% of such services were deemed to require improvement for patient safety and some could get even worse. “There is a significant number of services that are not achieving the level of safety they should,” he said.

He said many NHS maternity units were in danger of repeating fatal mistakes made at what became the University Hospitals of Morecambe Bay NHS foundation trust (UHMBT), despite a high profile 2015 report finding that a “lethal mix” of failings at almost every level led to the unnecessary deaths of one mother and 11 babies.

“Five years on from Morecombe Bay we have still not learned all the lessons,” Baker said. “[The] Morecombe Bay [report] did talk about about dysfunctional teams and midwives and obstetricians not working effectively together, and poor investigations without learning taking place. And I think those elements are what we are still finding in other services.”

Baker urged hospital managers to encourage staff to whistleblow about problems without fear of recrimination. He said: “The reason why people are frightened to raise concerns is because of the culture in the units in which they work. A healthy culture would mean that people routinely raise concerns. But raising concerns is regarded as being a difficult member of the team.”

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Source: The Guardian, 29 September 2020

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