Report finds more work to be done by maternity services in learning from failures

3rd September 2021 Clinical Negligence

In my role as a clinical negligence solicitor I have represent families who bring claims following substandard maternity care, and I have witnessed at first hand the profound consequences that such care can have on the child and their family. Often the family wants to ensure that lessons are learnt from the incident but in can be difficult to see what, if any, changes in practice are brought following a successful claim.

In recent years the government has made a number of commitments to improve maternity services and in summer 2020 the Health & Social Care (“H&SC”) Committee commissioned an independent panel of experts to report on the government’s progress in meeting its targets.

In July 2021 the Committee published their report which analysed the government’s performance against a number of key objectives including:


(1)        Supporting maternity services and staff to deliver safe maternity care; and

(2)        Learning from patient safety incidents

The report comes against a background of recent high-profile maternity scandals at Shrewsbury & Telford Hospital NHS Trust and East Kent Hospitals University NHS Foundation Trust. 

There is a helpful timeline of recent milestones in maternity care in the H&SC report.  


Supporting Maternity Services & Staff to Deliver Safe Maternity Care

In November 2015 the government launched the National Maternity Ambition to reduce the rate of stillbirths, brain injuries, neonatal and maternal deaths by 50 per cent. .

In its report, the H&SC recognised the progress made towards this ambition but concluded that further improvements were required towards safe staffing and training, noting the current shortage of midwives, obstetricians and other healthcare professionals involved in maternity care.  It recommended that further funding was required to deliver safe staffing levels.

The H&SC also noted that further improvements are  needed to be made in terms of training.  The H&SC heard that in 2017/2018 fewer than 80 per cent  of NHS trusts were providing all the training set out in the Saving Babies Lives Care Bundle provided by Baby Lifeline.

Learning From Patient Safety Incidents

The H&SC noted that involving families in a compassionate manner is a crucial part of the investigation process.  Too often, maternity investigations have failed to do this in a meaningful way.  The H&SC also noted that families must be confident that their voices are heard and that lessons have been learnt to prevent the tragedy they have endured being repeated.  These are comments that I would fully endorse.

The H&SC considered that the Healthcare Safety Investigation Branch, launched in 2018 with the aim of conducting independent maternity safety investigations in order to identify learning points, was a valuable step in the right direction to learning from incidents but that there was more work to be done.

The recommendations are to be welcomed as another vital step in improving maternity services, I will be interested to see how the Government responds to the report.  

The report also highlights why it remains vital for families to have an independent and specialist Solicitor looking after their child’s best interests.



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Steven Brown is a Partner located in Manchesterin our Clinical Negligence department

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