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World Patient Safety Day 2021 – Maternity Care Matters: Learning After harm

By Guy Forster, Medical Negligence Partner at Irwin Mitchell

The World Health Organisation has launched 2021’s World Patient Safety Day, this year focussing on the need to prioritise and address safety in maternal and newborn care, particularly around the time of childbirth when most harm occurs.

Maternity injuries have a life-changing impact

There is no getting away from the fact that, when things go wrong, the impact can be profound for everyone involved, not just for those harmed and their families but the healthcare professionals involved too. 

The injuries sustained by babies and their mothers can be life-changing and result in the need for extensive professional care, therapy, equipment, housing and other needs. The financial cost can be substantial but so too is the human cost for those who are left to pick up the pieces.

Work to improve maternity services

In the UK, there has been a lot of work done by many to tackle the ongoing problems we see in maternity care with some brilliant work done by healthcare organisations, not-for-profits and charities. 

We’ve seen some encouraging progress with rates of stillbirth continuing to decrease in recent years but we still continue to see high rates of avoidable incidents and recurring themes such as inadequate monitoring and poor clinical decision making. 

The recent Health and Social Care Committee report on “The safety of maternity services in England” highlighted the ongoing challenges faced by NHS, recognising that only a joined up approach will enable us to make real in-roads. 

Staffing and resourcing, continuity and personalisation of care, training and good leadership are all key features, but it is improving the response the adverse incidents which is the one which chimes with me most as a solicitor representing families affected by birth injury, stillbirth and neonatal death.

Supporting families to establish answers

Sadly, clients often come to us having had unsatisfactory experiences with NHS complaints or internal investigations. They perceive that healthcare professionals have “closed ranks”; investigating a clinical negligence claim is a last resort in a bid to gain answers, seek change and achieve justice. 

The focus of the Healthcare Safety Investigation Branch (HSIB) in maternity care has helped greatly to improve the quality of investigations and subsequent learning and reinforces the long held view that external scrutiny avoids many of the pitfalls of internal investigations, such as issues of bias, lack of insight and barriers to sharing best practice. 

All too often the early exchanges between patient and healthcare organisation can lack the thoroughness, candour and sincerity needed. This in turn drives animosity and can hinder everyone from moving forward in a constructive way. 

There needs to be a more rigorous framework for independent investigation of patient safety incidents and better engagement with families, including the early use of mediation, to ensure an open and non-hierarchical discussion. If we improve short term responses to incidents, we create an environment in which patient safety learning can thrive.

Culture of collaboration is key to improving care

As lawyers we have a key positive role to play in all of this. It is often said that a system which is adversarial in nature only encourages animosity, delay, rising costs and consequently opportunities to learn are missed. Sometimes the criticism is levelled at us that we are promoting a “blame culture”. 

There is perhaps a lack of understanding of just how much effort lawyers on both sides are now putting into improving the culture of collaboration. 

In its annual report for 2021, NHS Resolution made a particular point of attributing the reduction of legal cost to “a greater cooperation between the parties”. For specialist lawyers, there is great value in good working relations with their counterparts. The advantage of early and constructive engagement means that cases are dealt with more quickly and efficiently, at less cost and provide further opportunities for patient safety learning. 

Amongst these processes and systems, we can set the tone for a working relationship which prioritises the needs of those who are harmed in healthcare. The most effective environments are often those where there is a genuine understanding of who needs what, rather than making assumptions and blindly channelling families, healthcare professionals and others down a pre-determined system, from serious untoward investigation to litigation, without giving enough thought as to how we best achieve positive outcomes for all. 

By doing so we can build in principles of restorative practice which helps all involved to avoid conflict, build relationships and repair harm by enabling effective and positive communication.

Maternity safety webinar

The role of restorative practice in maternity safety is being explored from 5pm today during a webinar led by the Harmed Patients Alliance and Baby Lifeline and I wold encourage anyone interested in improving learning after harm and the lived experiences of all those involved to sign up and join in the conversation.

Of course, the best way to tackle the rising cost and other consequences of medical negligence is to prevent harm from occurring in the first place and better resourcing for the early responses to patient safety incidents will go a long way to achieving that aim. 

There are many different stakeholders who can help improve the system but, as specialist legal advisors dealing with the fall-out from these difficult and often tragic situations, we can be a key part of the solution.

Find out more about Irwin Mitchell's expertise in supporting families affected by maternity care issues at our dedicated birth injuries section.

More information about the webinar and how to sign up can be found via the link below. 

“If we improve short term responses to incidents, we create an environment in which patient safety learning can thrive. As lawyers we have a key positive role to play in all of this. “”