Patient Safety Watch: Jeremy Hunt: I was told we had moved on from ‘normal birth’ ideology – I was misinformed

Good afternoon, and welcome to this fortnight’s edition of the Patient Safety Watch newsletter – this time from me, Jeremy.

Is an end to dangerous ‘normal birth’ ideology finally in sight?

Maternity safety has once again dominated headlines over the past two weeks. A superb investigation by journalist and patient safety advocate Shaun Lintern in The Sunday Times has raised serious concerns about the culture and quality of university midwifery programmes.

The reporting prompted a strong reaction – notably from the Royal College of Midwives (RCM), which issued surprisingly strong criticism of the Nursing and Midwifery Council (NMC) for weak oversight.

Gill Walton, RCM chief executive, said: “Midwifery students should be supported by a system that prepares them for the realities of modern maternity care. Right now, weak and inconsistent oversight from the NMC is failing midwifery education – for those delivering it, for students, and for women and families.”

One of the most troubling elements was the testimony from student midwives. One told the paper: “There is a lot of emphasis on normal births. There’s so little care about safety from that education side that I don’t know how we can expect midwives to be so focused on safety. It’s almost like you’re being set up to fail a lot of the time.”

When I was health secretary, the persistence of a “normal birth” ideology – and its tragic consequences – came up repeatedly, but I was always told the system had moved on. It is clear from Mr Lintern’s investigation that I was being misinformed, with some dangerous ideology still lingering on. As I wrote in The Sunday Times, childbirth is not meant to be a test of endurance: what matters is what is safe. Baroness Amos’s review is a big opportunity to make sure no mother finds herself or her baby at risk because she is not given the right information about the safest course of action.

How do we stop safety recommendations gathering dust?

Sticking with maternity safety, new analysis in the BMJ has revealed that coroners’ recommendations following maternal deaths are frequently ignored.

The study reviewed 10 years of Prevention of Future Deaths (PFD) reports and found that nearly two-thirds had no documented action taken in response. The issues raised – from failures in escalation to gaps in monitoring, staffing and training – echo themes seen repeatedly in maternity inquiries.

This may be unlawful given that organisations are legally required to respond to such notices within 56 days. But more worrying is the pattern: recommendation after recommendation gathering dust. We desperately need a system that logs and prioritises recommendations with proper accountability for implementing them. The Patient Safety All-Party Parliamentary Group I chair had a good meeting with Penny Dash and Sir Mike Richards to discuss how to do this. Our solution is in this document.

It should be a solvable problem, but for a salutary reminder of how national safety initiatives can get turned into box-ticking exercises by the time they reach the front line, take a read of this excellent new book by Lorin Lakasing.

Ending unfair compensation for poorer families

Finally on maternity safety, The Observer has reported that Wes Streeting intends to end the shocking anomaly whereby poorer families receive significantly lower compensation than wealthier families when their babies are left avoidably brain-damaged at birth.

This is a welcome commitment. But if we are serious about improving maternity safety, we must also look at more comprehensive reform of the litigation system. Japan’s no-fault compensation scheme for birth injury is a compelling example of what could be achieved with a more just and safety-focused approach – and led to a 25 per cent fall in the number of babies born with severe cerebral palsy.

In other news…

Kingdon audiology investigation: important lessons for child health services

The recent Kingdon Review of children’s hearing services has revealed profound and systemic failures across the NHS and Department of Health and Social Care that left hundreds of babies and young children with undetected hearing problems, leading to lifelong developmental harm.

Dr Kingdon’s report makes 12 urgent recommendations to reset the system: from strengthening national oversight, integrating services into clinically connected networks, and building a unified professional register, to investing in workforce development, training, and research. Another report we need to make sure doesn’t gather dust…

New men’s health strategy launched

The government has launched England’s first Men’s Health Strategy, acknowledging long-standing inequalities that leave men at higher risk of early death, suicide, cancer, and cardiovascular disease.

Key measures include funding for local men’s health projects, new suicide-prevention programmes and improved training for NHS staff. From 2027, men on active prostate cancer monitoring may be able to order home PSA tests via the NHS App. The strategy also commits to targeted research and action in areas with the poorest male health outcomes. I am always shocked by one statistic in particular, namely that suicide is the single leading cause of death for men under 50.

Hospitals continued using high-risk heart device despite warnings

A BBC News investigation has revealed that two major transplant centres – Newcastle’s Freeman Hospital and London’s Harefield Hospital – continued using a Medtronic heart pump despite clear evidence that it carried far higher risks of complications than its alternative. In particular, NHS audits in 2018–19 showed 45 per cent of patients fitted with the Medtronic HVAD died within two years, compared with 15 per cent for the Abbott HeartMate III. 

However, both hospitals questioned the NHS data and kept implanting the device until 2021, when Medtronic issued a safety notice and later withdrew the device. Affected families and patient representatives are understandably calling for an independent investigation into how these avoidable risks were allowed to continue. The BBC investigation also revealed that leading cardiologists at both hospitals were paid consultants for the manufacturer, something the hospitals were aware of. 

For me, these circumstances raise an important question about the existing duty of candour, which focuses on retrospective harm. But if information is available about known patient safety risks, shouldn’t there also be an active duty on healthcare providers to proactively share this information with patients and families? An issue the APPG on Patient Safety will be thinking about.

One in five A&E patients treated in corridors

New Royal College of Emergency Medicine (RCEM) research (for the APPG on Emergency Care) shows that nearly one in five patients in English emergency departments were being treated on trolleys or chairs in corridors, waiting rooms or other spaces not meant for clinical care.

The report called corridor care a “national shame”, which few would disagree with. It warns that it reflects deeper system-wide pressures and that a lack of staffed inpatient beds, delayed discharges, and gaps in social care are causing serious harm.

HSSIB patient safety education review – Have your say

The Health Services Safety Investigations Body (HSSIB) is reviewing its patient safety education programme and is inviting healthcare professionals and stakeholders to share their views. HSSIB currently offers CPD-accredited courses on systems-based investigation, human factors, and patient safety learning, supporting the NHS Patient Safety Incident Response Framework.

HSSIB is seeking feedback on course content, delivery, and accessibility to make sure it meets the needs of investigators and healthcare staff across the system. 

Thanks for making it to the end of this edition and for your interest in patient safety. Sometimes, when I think of all the effort put into patient safety campaigning, I remember the famous quote often attributed to Churchill: “Success is not final… it is the courage to continue that counts.”

Jeremy