Maternity Investigations: What have we learnt?

Having worked in and around maternity services for over 30 years, I have had a long and varied career, with patient safety and working towards safer maternity care being my priority always. 

Aside from the consideration of Shropshire’s Maternity Services, in the Shrewsbury and Telford report, a strong theme that ran through our report, published in March 2022, was the challenges faced by maternity services in England today. There was a particular emphasis upon insufficient funding affecting NHS maternity services, which, as we all know, has had a serious impact on maternity care across the country. The multi-professional maternity team working effectively together is vital to the delivery of both safe maternity care, and a safe and supportive environment to speak up. 

With the Immediate and Essential Actions arising from Shrewsbury and other reports that followed, including the East Kent report, and The Muslim Women’s Network “Invisible” report, on the experiences of many women in our maternity services, the real questions to ask ourselves are what do we know, what have we learnt, and what are we yet to do?  

According to the Office for National Statistics more than 600,000 babies are born in England and Wales every year and approximately a quarter of those women giving birth are from minority ethnic groups. 

In 2022, there were 605,479 live births in England and Wales. Of course, all women, regardless of where they live, should have positive maternity experiences – A national survey by the Care Quality Commission indicates that the majority of women using our maternity services, over 80%, do have a positive experience of maternity services, but that the standard of care does fall short for some women.  

I have always been very clear about the fact that patient safety is at the heart of everything I do and firmly believe that even one poor outcome, is one too many –  I have seen first-hand that the consequence of poor outcomes, even for a minority of women, are often life changing, breaking hearts, families, and homes.  The consequences of maternity harm remains with families forever. 

Today, maternity incidents remain the single highest cost of claims against the NHS in England. Of these claims, Obstetric claims remain the largest proportion, representing nearly 12% of the number of the total number of 13,551 new claims reported in 2022/23. Just a few months ago, the case of Wynter Andrews was widely discussed on national media, after Wynter, baby daughter to Gary and Sarah Andrews, died at only 23 minutes old, resulting in the Trust being fined by the CQC £800,000 pounds after it was ruled that Wynter’s death was preventable.   

In April 2023, the Runnymede Trust, the UK’s leading independent race equality charity, released their anticipated report on the experiences of people living in Britain, concluding that Britain is still far from being a “racially just society”, with the data showing that more than a third of people from ethnic and religious minority backgrounds have experienced racially motivated abuse of some form. This is where the Muslim Women’s Network’s “Invisible” report comes in, reporting that many women felt dismissed by their care team, citing cases where South Asian women (particularly those that struggle speaking English) are assumed to be exaggerating their health concerns, with one woman being told by her doctor that she saw “five of you lot every day”.  

These barriers, be they racial, social, or financial, serve to really highlight the importance of speaking up, experiencing this, day in, day out, starts to make a person think that speaking up, either as a patient or staff member is futile, that nothing will change.  

To conclude, I cannot stress enough the importance of speaking up. Improving patient safety is at the heart of everything I do, and it cannot be achieved without everyone feeling that they have the freedom to speak up about their experiences, and that what they say matters. In order to make patient safety and inclusion our priority, we need to create a culture where ‘speaking up’ is not just promoted, but an integral part of life working in and around the NHS.