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The importance of listening to women, and having open, honest dialogues were just some of the key messages from this year’s Baby Lifeline Maternity Safety Conference.
Specialist patient safety lawyers from Novum Law, Mary Smith and Hannah Carr, attended the event, bringing maternity professionals, leaders, specialists, patients, and families together to discuss maternity care safety.
Organised by the charity Baby Lifeline, which promotes the safe care of pregnant women and new born babies all over the UK and worldwide, the event shared examples of positive improvements and best practices for maternity services.
Delegates also had an opportunity to hear from senior leaders about the next steps in the national maternity safety programme.
The Rt Hon Jeremy Hunt MP provided an opening address on safer maternity care with the encouraging news that there has been a 30% reduction in neonatal deaths.
Conference attendees were moved to hear Nadine Montgomery’s story. She spoke candidly about her son Sam’s preventable birth injury and her family’s 15-year fight, which resulted in the Courts changing the law about consent. It is now a legal requirement that patients are made aware of any material risks involved in any recommended treatment. They should also be told about any reasonable alternatives.
Nadine said: “the paternalistic model has been the model for too long… patients are capable of making their own decisions, but we need the support of our doctors.”
Delegates heard that maternity litigation costs the NHS some £4.1billion per year, equating to £6,700 per birth in England. Therefore, investments in safety must be made to improve learning opportunities for healthcare staff and improve outcomes for all.
The Chief Inspector of Hospitals at the Care Quality Commission (CQC), Ted Baker, praised maternity staff for coming forward and being honest about safety in their units. He highlighted the importance of a culture where hospital trusts can learn from mistakes – with honesty and transparency at the centre.
Professor James Walker, the Clinical Director in Maternity of the Healthcare Safety Investigation Branch (HSIB), emphasised collaboration to improve maternity safety. He observed that “no one group can solve all the problems… We must work together to implement change. The patient’s voice is vital, and family involvement in any investigation is key as well as staff and trust engagement and shared learning.”
Learning was a central theme in Dr Denise Chaffer, Director of Safety and Learning at NHS Resolution’s presentation. She said: “We can be better at responding at the point of the incident – putting our arms around patients, offering a meaningful apology and a compassionate response.”
Strong leadership in maternity units is vital to ensure healthcare staff learn from mistakes. This means a culture with non-hierarchal behaviours and opportunities for doctors, nurses and midwives to learn from events and share that learning.
During his address, Sir Liam Donaldson, Patient Safety Envoy for the World Health Organization, observed that “… blame culture is the worst possible way of progressing patient safety…Make zero avoidable harm to patients a state of mind and a rule of engagement in the planning and delivery of healthcare….”
Charlotte Bevan, Senior Research and Prevention Advisor for Sands talked about the importance of engaging parents early in reviews when things go wrong.
When parents are engaged early on, any escalation, whether that’s by way of complaints or litigation, can often be avoided
Parents must be at the heart of the story – it is their narrative. They want answers when things have gone wrong, and they want meaningful apologies when they are due.
Baroness Julia Cumberlege, CBE, Chair of the Maternity Review and author of the report ‘Better Births – Improving outcomes of maternity services in England’ concluded, saying: “We mustn’t make exceptions. Our services must be right for all.”
She called for more sustained funding for maternity and neonatal services and observed that this would not be just for this year but for the years to come. She also emphasised that there needs to be a focus on staff. Good leaders in our maternity units are an invaluable part of this.
Speaking after the Baby Lifeline conference, Novum Law specialist medical negligence solicitor Hannah Carr said:
“This was an important event bringing together the UK’s leading experts on maternity care to discuss the steps that need to be taken towards achieving the national ambition in maternity to halve the 2010 rates of stillbirths, neonatal and maternal deaths and brain injuries occurring during or soon after birth by 2025. And to develop more woman-centred care that promotes choice, personalisation, and parent engagement.
“It is crucial that we continue to raise awareness of the need to continually improve maternity services through training, development, cultural change, and by ensuring that vital lessons are learned when things go badly wrong.”
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