Patient Safety Watch: For safer maternity care, we need action, not words

Good afternoon, and welcome to the latest edition of the Patient Safety Watch Newsletter – this time from the other member of the duo, Jeremy.

Let me start with a really difficult issue, the safeness of the Lucy Letby conviction. This week, I wrote in the Daily Mail that the Criminal Cases Review Commission (CCRC) should urgently review it. I did so after a lot of soul-searching: partly because I believe in the separation of powers, so politicians should never second-guess the courts (which is why I make no claim about Ms Letby’s innocence or guilt). But partly because bereaved families who have suffered unspeakably, may have hoped the matter was now over, and therefore will find continued debate on the issue very distressing.

But in the end, patient safety concerns compelled me to speak out. If medical error caused the tragic deaths at the Countess of Chester, then we need to know why – and stop the same mistakes being repeated. Some evidence suggests the spike in deaths is no worse than in other hospitals. How the deaths were linked to Ms Letby is also under question, not by conspiracy theorists but respected doctors like Mike Bewick, with whom I worked closely when he was at NHS England. For everyone’s sake, we need the CCRC to move faster than its normal glacial pace.

In other news…

Is it time for a national maternity safety inquiry?

We have had Morecambe Bay, Shrewsbury and Telford, East Kent, and Nottingham. And now we have Leeds Teaching Hospitals Trust, where 50 more families have raised concerns about the provider’s maternity care. The trust has acknowledged “failings in care” but insists progress is being made. However, a new Care Quality Commission report, published today, has downgraded the service from “good” to “inadequate”, adding failings in the service posed a “significant risk” to women and babies.

Families understandably want a full inquiry, while harmed families in places like Sussex and Oxford are making similar calls for local inquiries. There are also requests for a statutory judge-led national inquiry into maternity safety, which Wes Streeting is reportedly considering.

My answer would be to be careful what you wish for. We need action, not words – for example, by implementing the 15 immediate and essential actions from Donna Ockenden’s Shrewsbury and Telford report. Judge-led inquiries allow ministers to tell Parliament they need to wait until the outcome of the report before taking action. A swifter approach is to set up a non-judicial panel, such as by Bishop James Jones in the Hillsborough Inquiry, but that still took two and a half years. With nearly three preventable baby deaths every day, whatever Mr Streeting does must not be at the expense of urgent action.

Trusts penalised over exaggerated maternity safety claims

On a related note, dozens of trusts have faced financial penalties after claiming compliance with maternity safety standards they failed to meet. The Maternity Incentive Scheme gives trusts refunds from NHS Resolution fees if they meet 10 key safety actions, including appropriate staffing and board oversight.

However, analysis by HSJ found that between 2018 and 2022, 24 trusts had to repay funds, with 18 making multiple repayments. These include trusts at the centre of high-profile maternity failings such as East Kent, Shrewsbury and Telford, and Nottingham University Hospitals – the latter of which is currently under criminal investigation.

I set up the Maternity Incentive Scheme. I am afraid it has become a tick-box exercise in need of a major overhaul.

Trust and manager cleared of manslaughter after patient suicide

North East London Foundation Trust and a ward manager have been found not guilty of manslaughter following the death of 22-year-old Alice Figueiredo, who took her life while under inpatient care.

During the case, several allegations were made about care failings at the trust, including failures to record self-harm incidents and failures to remove items from the ward which Ms Figueiredo had used to harm herself previously. The trust and ward manager, Benjamin Aninakwa, were each found guilty of a health and safety offence. 

I do not question the court judgment, but simply ask why we tolerate any inpatient suicides in mental health units? Best practice should be to work towards zero deaths, as Mersey Care successfully achieved under Joe Rafferty’s leadership.

NHS blood supplies at risk as stocks dwindle

NHS Blood and Transplant is urging thousands of new donors to come forward urgently, as blood stocks fall to dangerously low levels. According to The Guardian, without increased donations, England could enter a “red alert” status, potentially delaying non-urgent care. Type O negative blood is in particularly short supply.

And on to some more positive stuff…

New podcast episode: Restoring trust after harm

Try this promising podcast on how restorative practice can transform the way organisations respond to healthcare harm, moving beyond traditional investigations to truly acknowledge the needs of those affected. It’s in Stories of Safety with Professor Jane O’Hara and Dr Jo Wailling, and well worth a listen, particularly on the additional suffering that can result from how organisations respond when things go wrong. Out on 23 June.

Share your safety interventions: Falls, pressure ulcers, and medication

As mentioned in previous newsletters, Patient Safety Watch is gathering insights from frontline staff who’ve led or contributed to safety improvement projects in NHS hospitals. We’re especially keen to hear about interventions addressing:

• Falls prevention
• Pressure ulcer reduction
• Medication safety

Whether you’ve designed an intervention, supported its rollout, or helped evaluate its impact, we want to learn from your experience.

Take our short survey to help us capture what’s working and share learnings that can benefit hospitals everywhere.

Congratulations to Peter Walsh – MBE for services to patient safety

Finally, heartfelt congratulations to Peter Walsh, awarded an MBE in last week’s King’s Birthday Honours for services to patient safety and justice.

Peter, former Action against Medical Accidents chief executive, led the charity for more than 20 years and remains a powerful advocate for patients and families. I worked with him for many years and can truly say his recognition is richly deserved.

That’s all for now – next newsletter from James in a fortnight.

Jeremy