Latest / The Fourcast / 'A culture of cover-up': the NHS maternity crisis exposed

Transcript

'A culture of cover-up': the NHS maternity crisis exposed · The Fourcast

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The NHS is very dysfunctional. People are just terrified that
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if they're honest about what went wrong, they're going to get
0:07
scapegoated and we end up, I'm afraid, with a culture of cover.
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Up We're not just looking at a cover up culture, we're looking
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at a blaming culture. We were blamed as families for
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the deaths of our babies because they couldn't accept that
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accountability. Stories that we keep hearing
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time and again. Babies who have unnecessarily
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died, been harmed, families left bereft.
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Now, I'm sure there have been some improvements, but because I
0:32
am still doing these heartbreaking stories, you know,
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not enough is changing. Hello and welcome to the
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forecast. The NHS is facing one of its
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deepest crises, a string of maternity scandals.
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From Shrewsbury to Nottingham, Oxford to Leeds, hundreds of
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babies have died or been left severely injured in hospitals
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meant to keep them safe. So why does this keep happening?
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Is it about funding, training or a system that protects itself
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instead of patients? To discuss all of this, I'm
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joined by the former health secretary Jeremy Hunt, who
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commissioned one of the first major maternity inquiries, a
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health and social care editor, Victoria McDonald, who's been
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investigating these scandals for years, and Kayleigh Griffiths, a
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campaigner who lost her daughter in one of the NHS's worst
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maternity failures. Thank you all very much for
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joining us, Victoria. First of all, you've done a
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series of stories in the last few days.
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Why are we here again? Well, we've been looking with
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the New Statesman at Oxford University Hospitals Trust,
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maternity and neonatal units, and it's the same story again of
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babies who have unnecessarily died, been harmed, mothers
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harmed, families left bereft and against a background of
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defensiveness in the trust of parents not being listened to,
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of a lack of duty, of candor, The same thing that we've heard
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over and over again. One mother who had twins who
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were born at 24 weeks, one of the twins was taken away, wasn't
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resuscitated, was then brought back to the mother saying, oh,
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the morgue wouldn't be able to take this baby because it's
2:07
still breathing. And she was left with this baby
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having to keep it warm on the radiator until it died.
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Those sort of stories that we keep hearing time and again.
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Kayleigh I mean, after such a long and difficult public battle
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for you, how did hearing about another series of disasters make
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you feel? I mean, for me, it's just
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heartbreaking having to listen to the same, the same thing and
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the same stories over and over again.
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And I mean, to, to take a baby back to its mother that was
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still breathing. I mean, I just can't even
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comprehend that, that somebody would do that.
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But I mean, fundamentally, we know what the issues are.
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We've, we've heard time and time again that, you know, we know
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the issues, but we're just coming up with a barrier of
2:54
actually implementing any of these recommendations.
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And it's we, we just, you know, we need seriously to get to the
3:00
bottom of what, what, what the barriers are and get, get these
3:04
recommendations implemented now. Jeremy, why is it so hard to get
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these things changed? It's hard partly because the NHS
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is very dysfunctional. So everyone has this idea that
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it's a a centralised well run machine where someone at the
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Department of Health or NHS England can say do this and
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tomorrow every maternity unit in the country does it.
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Unfortunately it doesn't work like that because you know,
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these maternity units are very busy places and the doctors, the
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midwives, the nurses have got a lot on their plate.
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And the thing which is most disappointing is that you can
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have a mistake say in Blackpool and a coroner can say we need to
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change the system so that this doesn't happen again.
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And then exactly the same thing will happen in Oxford or
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Cornwall, you know, a few months later.
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And I think the thing that worries me the most, Krish, in a
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situation we're in is that we've got into this mentality of
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uncovering another scandal at yet another hospital.
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And I think we need to be honest, we've got these problems
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throughout the NHS. Let's let's stop saying this is
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a particular issue at Shrewsbury or Morecambe Bay or or Leeds or
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Oxford. You know, throughout the NHS we
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have got profound problems in the way we deliver maternity
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services and we really do need change.
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Right. But to to what extent is the
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defensiveness of the NHS the fact that people's jobs are on
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the line and they will inevitably try and fight for
4:44
their own position at the core of the problem?
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Well, I think that is the biggest problem that we have.
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And I think, look, I don't want to be defensive because these
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stories are heartbreaking. It's heartbreaking for me
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because I, you know, when I was health secretary, this was
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probably my absolute top priority.
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But I think it is worth saying that since the original
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Morecambe Bay statement that I gave to Parliament in 2015 that
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the Kirkut report, baby deaths have fallen by about 20% across
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the NHS and the number of children born at term with
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severe disabilities is down by nearly 1/3.
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So there has been some progress made, but it's not enough.
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And I think at the heart of it is a really big problem that if
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you are a, an obstetrician or a midwife and you make a mistake
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and there's a tragedy as a result of it.
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You worry that if you're open and transparent about what
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happened, you, you, you hold your hand up.
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You say, I think I may have made a mistake, I should have done
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this, but instead I did that. You worry that you're going to
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get fired. And we have not learnt in the
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NHS to do what they do in the airline industry, which is
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distinguished between gross negligence, you know, a pilot
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turning up to fly a plane when they're drunk, for example,
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which there is, you know, there can be no forgiveness.
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They should never fly again. And the kind of ordinary human
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errors that everyone can make. And because we don't do that,
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people are just terrified that if they're honest about what
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went wrong, they're going to get scapegoated and we end up, I'm
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afraid, with a culture of cover up.
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I mean, Victoria, I mean, in your stories this week, you, you
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didn't just uncover defensiveness, you uncovered
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aggression. Yes, well, that is true.
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I mean, there were some extraordinary legal letters sent
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and and which we can't go into too much, but the but I, I agree
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to a certain extent with Jeremy Hunt on the the sort of culture
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and they being too scared to put your head above the parapet.
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But I think it goes further than that.
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I think it is there is so much more about the way people are
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trained, the way, the way that the NHS has been starved of
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money. And, you know, let's not forget
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that that Mister Hunt was there during the, the time of
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austerity When, when, you know, spending was not keeping up with
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inflation. And I think it has progressed
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from there. There's also this idea of the,
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the NHS always being, you know, turned upside down and
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reorganized and, and it has just left people exhausted and not
7:23
wanting to do the right thing, which has put their hands up.
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There is also a litigious element to this.
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So we had one story where this this baby was the the consultant
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left the room during the caesarean section, left it to a
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more junior member of staff, came back in, it was all going
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wrong, yanked the baby out with some faucets and that baby is
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now quadriplegic. Now that surgeon did say to the
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the parents, I'm really sorry. Took 12 years for the trust to
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admit 100% of liability. That story spoke to me volumes
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of what is going wrong on the maternity units.
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Kayleigh, to what extent do you think this combination of
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defensiveness, legality and resourcing is at the centre of
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this? And I think massively at the
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centre of this. I mean, when you look at we're
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not, we're not just looking at a cover up culture, we're looking
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at a blaming culture that, that, that not necessarily within the
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NHS, but we were blamed as families for the deaths of our
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babies because they couldn't accept that accountability.
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And when we look at accountability, has anybody
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actually been held accountable for the continuous failures that
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have been uncovered within maternity services?
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Because we were promised accountability when Ockendon was
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published. But actually we've, we've had
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nothing to date. And I think, I think denial
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because as, as Derek Richard said, the grandfather of, of
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Harry, denial is the biggest thief of learning.
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And by blaming the parents, not listening to the parents, not
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listening to whistleblowers, all that we ever wanted was, was
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learning from, from Pippa's death.
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And, and actually it, it was just so counteractive.
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We've never, you know, I've never as as a bereaved parent
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wanted to blame somebody. All I ever wanted was to
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actually work with that hospital, to put systems into
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place that made sure that that never happened again.
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And with this culture that's, that's, you know, continuing, we
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just can't, we can't get past that.
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We can never work together currently by without addressing
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those problems. Jeremy, what, what, what about
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resourcing? I mean, when, when you're
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changing the way a system runs, you know, are you able to
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adequately think about culture and the way people think and
9:56
approach accountability as well? Well, I think, you know,
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accountability and resourcing are two different things.
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I mean, on the resourcing side, when I became health secretary,
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the first thing I dealt with was Mid Staffs and everyone said to
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me, I'm sure you probably did in a Channel 4 interview.
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You know, the, the issue here is short staffing.
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We don't have enough, you know, nurses in the wards.
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And so that's why I made every hospital publish the number of
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nurses they had on every shift in every ward.
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And we saw a big increase in staffing.
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And so, I mean, over the last decade in maternity, for
10:34
example, midwives is up 11%, nurses, maternity nurses up a
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third, obstetricians up nearly 2/3.
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So it's been quite a big increase.
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But unfortunately, we haven't seen a commensurate fall in the
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number of tragedies like Pippa's tragedy.
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And I think that this defensiveness is the thing that
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worries me the most. So many parents that I speak to
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say exactly the same thing. They're not looking to blame
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anyone, but they also say that very often when something goes
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wrong, literally the only person who's on their side is a lawyer
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and they therefore end up in these very protracted legal
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disputes which take 57, as Victoria said, 12 years.
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And during any kind of litigation, hospital doctors,
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sorry, hospital lawyers, tell doctors not to say anything at
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all or say the very bare minimum necessary.
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And, you know, I really think we need to look at whether we
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should have no fault compensation where compensation
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is automatic when someone has been wronged by the NHS.
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It's the system they have in New Zealand.
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Overall, it doesn't cost, it costs actually less than the the
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bill that we pay here for clinical negligence.
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And I'll just give you one example because I think it boils
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down to, you know, Derek Richford's point about learning
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in Japan, they introduced no fault compensation for babies
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born with severe cerebral palsy. And they did it about 15 years
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ago. And since then, they saw a fall
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in about 1/3 of the babies born with severe CP.
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And the reason was because instead of getting involved in
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very complex, expensive court cases, parents got automatic
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compensation. And hospitals can concentrate on
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learning from what went wrong. And it's that learning culture.
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I feel that, you know, that the midwives and nurses and doctors
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involved, when these things go wrong, they actually want
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nothing more than to really learn from it and to make sure
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the same mistake is not repeated.
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But the structures we put in place make that virtually
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impossible. I think one of the things that
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hasn't been discussed actually here is training and it's not
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just the way there was a change in in the way midwives were
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changed. So they're trained, they're now
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do three years of training. Before they used to have to be a
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nurse and then go on to do specialist.
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And I think there is an issue with that.
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I was talking to an obstetrician the other day who said, look,
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the fact is that birth birthing has become more problematic
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these days because women are older, they have more complex
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conditions. You know, it's, it's always been
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a difficult, you know, there have always been problems, but
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it's getting harder and harder and the training is not
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necessarily keeping up with that.
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There is also a terrible hierarchical issue on the wards.
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So what you will hear time and again is a midwife or a nurse
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will want to escalate a problem and the doctor isn't hearing it,
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or they're not there, you know, they're not in the room, or some
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junior member of staff just won't want to say anything and
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they sit on the problem. All of that, I suppose, comes
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back to the culture, but it does come back to the way training
14:01
needs to change. I mean, I'm speaking as somebody
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who had a baby at 47. I mean, I fall into that cohort
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of, you know, problematic older women giving birth.
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But you can see this that the General Medical Council did try
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at some stage, and I'm not sure if they're still doing it, to
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get obstetricians and gynaecologists and nurses and
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midwives to do some training together so that they could try
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and deal with this hierarchical issue that that puts up such a
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barrier on the ward when something's going wrong.
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Jeremy. I agree with that and I think
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that one of the biggest issues in training is on midwife
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training where there is still a culture of so-called normal
14:47
births of trying to avoid getting a doctor involved in a
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birth. And there was a big Sunday Times
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investigation into this just this weekend.
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And the issue is that sometimes it's taking too long for people
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to get referred to a doctor where maybe AC section is the
15:05
safest thing for a baby in a particularly complex situation.
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And the training colleges all have been saying for some time
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they don't do this anymore. But the truth is that this still
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does exist. And I do think that you're
15:21
absolutely right, Victoria. Teamwork and a culture that in
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the end the only thing that matters is safety of mother and
15:28
child. That is the the most important
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thing. Of course a woman must make the
15:34
final decision as to how a child is going to be born, but no
15:38
woman in practice would ever want to do anything but the
15:41
safest route. And sometimes they aren't given
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that information. Kaylee, do you have a sense of
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what needs to be done to drive that cultural change amongst
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staff? You know, is it, is it just, is
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it a matter of training or is it something beyond that?
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I would say it's, it's training, it's, it comes down to funding.
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You know, we're seeing the NHS being significantly stripped
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now. That's why I work in, in the NHS
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from a different type of trust, not an acute trust.
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And we're seeing cuts that are coming down the line and it's
16:13
constant. And what we're seeing across the
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board is, is burnout. We're seeing people that are
16:20
afraid to speak up, that, you know, whistleblowers are afraid
16:25
to speak out. It's, it's systemic, it's it's
16:29
culture, it's funding, it's improper regulation, it's
16:33
improper oversight that it's, it's huge.
16:36
Jeremy, can we, can we just focus on the, on the funding for
16:38
a second because both Victoria and Katie have raised it.
16:40
I mean, in your previous answer you seem to be sort of
16:42
suggesting it wasn't really about resourcing, Is that what
16:45
you're saying? Well, look, I don't want to
16:49
pretend that the NHS hasn't had a very difficult period.
16:52
I mean, what the the budget for the NHS in the 2010, I think it
16:58
was frozen in real terms. It wasn't cut.
17:01
But you know, there's been a lot of pressure in the NHS.
17:04
When I became health secretary about halfway through the
17:06
austerity period, I felt it needed more funding and I
17:10
secured a big increase in 2017 and it got a further increase in
17:16
the pandemic. I mean, you know, the facts are
17:20
that out of all the advanced economies, we, we're about the
17:23
fifth highest in terms of the proportion of our GDP we put
17:27
into health. So I, I think, you know, funding
17:31
has been an issue, but I also think it's about culture and I
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think it's about structures and it's about training.
17:39
It's about all the, all these things that we say.
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I think in terms of the actual question of the, the most
17:46
visible aspect of funding which is the number of staff that you
17:50
have. The the bit that is puzzling to
17:53
me is that you know, we've had about I talked about an 11%
17:57
increase in midwives. We've actually had about 11%
17:59
decrease in births because of a falling birth rate.
18:03
So, you know, it may well be that there are some return to
18:08
units that are short staffed, but I don't think that's the
18:11
only issue. And I think we have to look at
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why it is that when there's a problem, it seems to be so
18:17
difficult to get people to speak openly about it.
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And, you know, I, I introduced something called duty of candor,
18:26
which basically meant that it was against the law for
18:30
hospitals to be anything other than truthful to families like
18:34
Hayley's family. When there's a tragedy or when
18:38
there's any kind of patient safety incident, and I think
18:42
it's had some success, but it hasn't worked in the way that
18:45
I'd hoped. I was hoping there'll be a much
18:47
more profound openness happening in the system than we've seen.
18:52
So I think there are some deep seated cultural issues that we
18:55
need to look at as well. Can I just also ask you about
18:57
the regulation? Is the CQC fit for purpose?
19:00
It went really badly wrong after the pandemic, so I basically set
19:05
up the CQC in its current format and it's the way I set it up was
19:10
that you should have experts looking at hospitals.
19:15
So a maternity unit is not going to be investigated by a sort of
19:18
25 year old student on their first job.
19:21
It would be investigated by someone who was themselves a
19:24
trained midwife or trained obstetrician who knew what they
19:27
were looking for. And I think that is the right
19:31
way of doing it. In the pandemic, they after the
19:34
pandemic, they changed that system to generalist in struct,
19:38
in inspections. And that is now thankfully being
19:41
changed back. So I think the CQC is being put
19:44
back on its feet. But yes, it's had some very,
19:46
very big problems in recent years.
19:48
Victoria. Well, I mean, Kayleigh knows
19:51
better than I do. Perhaps you you can explain what
19:54
you and Rhiannon Davis, who's baby Kate died at Shrewsbury in
19:59
Telford. I mean actually did look at the
20:00
CQC and and found enormous problems with the way that they
20:04
were investigating. I mean, probably better for
20:06
Kayleigh to explain this. Yeah.
20:07
So Rhiannon and I undertook a piece of work.
20:11
We looked at all the focused CQC inspections that were undertaken
20:15
into maternity. So we, we, we read through all
20:19
of them. We found inconsistencies.
20:23
What we found was that previously, so trusts that were
20:28
failing in maternity were rated as good.
20:32
Once concerns were then raised by families, they were rated as
20:37
inadequate and failures then were were were spotted.
20:42
But to date I'm still seeing inconsistencies in the way that
20:46
they report. I don't think, I don't think
20:50
what what Jeremy said there about the sort of levels of
20:56
staff that you've got undertaking the inspections
20:59
currently. So they're, they're quite
21:02
inspectors are paid quite a low salary.
21:04
So I don't think you would expect that it attracts that
21:07
experience that that Jeremy would be expecting and they've,
21:13
you know, that then they're not able to pick it out where a
21:18
trust is failing and. And do you think patient groups
21:21
are taken seriously and and do you have a blueprint for how you
21:25
would change things, how you would make things better?
21:28
Yes. So we, we've, we've got, we've
21:31
got ideas. Those are family voices.
21:35
What I would like to see would be those services and the
21:39
families coming together to create the, the change in the
21:42
way forward. I don't.
21:43
I don't think it can be done in isolation.
21:46
I've seen like shoots, green shoots of high, high services
21:51
are working together with families, but there's still a
21:53
very, very long way to go. Jeremy, I mean, I don't know
21:56
whether you do you speak to West Streeting about these sorts of
21:58
things. I mean, is there, is there
22:00
cooperation? Is is is your experience passed
22:02
on and shared? Yeah, I've had, I've had a lot
22:06
of discussions with Wes. I think he is very committed to
22:09
this. We had a, a debate in Parliament
22:11
for Baby Loss Awareness Week and you know, unusually as Secretary
22:16
of State he came and sat through the whole debate.
22:19
He could have sent one of his junior ministers and he didn't.
22:23
And I think he recognises that. You know, what people like
22:27
Kaylee want is action. You know, we've had so many
22:30
reports now. I commissioned quite a lot of
22:32
them myself actually. And you know, in a way, rather
22:36
than more recommendations, for example, Donna Ockenden in her
22:39
reporting to Shrewsbury in Telford had a list of immediate
22:43
and essential actions. And we just need to get on and
22:46
implement those immediate and essential actions.
22:48
They are immediate and they are essential and we just need to
22:50
get on with them. Or if the government doesn't
22:52
want to do them, they need to say why they don't.
22:55
So I hope that this, you know, new review that Valerie Amos is
22:59
doing is going to report quickly and we can just crack on with
23:03
doing the things that we all know need to happen.
23:06
But I do hope that as part of that, we look really hard at
23:11
culture change and we ask the difficult question as to what it
23:15
would take for doctors, nurses, midwives to be open in the way
23:20
that families want them to be open.
23:22
Because that seems to me, you know, even if the answer we get
23:25
is uncomfortable, we should find out what it is that is stopping
23:28
that openness. Because I think that is the
23:31
heart of why families feel time after time that they're not
23:35
being told the truth and that, you know, instance have been
23:38
covered up. When you look back, I mean, are
23:40
there things you, you know, you wish you'd done?
23:42
I mean, or have they brought you back now and said, look, what
23:44
should we do that politicians maybe don't turn to first?
23:49
Do you have recommendations? Well, the thing that I would
23:52
really like to do is is end this litigation culture because I
23:58
feel that it is just a big barrier to, if you look at
24:01
Sweden, if we have the same maternity safety levels of
24:05
Sweden, we'd have one fewer baby dying every single day.
24:10
And that would be amazing if we could get to that level.
24:13
They're one of the safest in Europe, but they they don't have
24:18
this very adversarial system. As soon as there's a tragedy,
24:21
you know, all that has to happen in Sweden is that the doctors
24:23
say there was a mistake. They don't apportion blame, but
24:28
they just say there was a mistake.
24:30
What was supposed to happen didn't happen and then the
24:33
family automatically get compensation and everyone can
24:37
concentrate on trying to understand what went wrong and
24:40
how to stop it happening again. And that is the kind of positive
24:43
learning culture that somehow we need to get to in the NHS.
24:46
So finally, Victoria, what's are the next steps?
24:49
Well, we do have this rapid maternity review that's looking
24:53
into maternity services in England.
24:55
Now it's being led by Baroness Valerie Amos and that is due to
24:59
report next spring. Now I, I, I feel conflicted
25:04
about it. I mean, I'm glad that the
25:06
spotlight is on it. But as we have said repeatedly
25:09
through this, there have been any number of reports.
25:12
Ockendon and to Shrewsbury and Telford was three years ago with
25:15
those urgent must do now recommendations.
25:19
How many of them have been taken up?
25:21
I don't know. I remember talking to Bill Kirk
25:24
up after Morecambe Bay and I said to him what if they don't
25:29
introduce these recommendations? What if they don't follow
25:31
through on them? And he looked at me aghast as if
25:33
to say well of course they're going to.
25:35
Well, then I saw him at East Kent some years later when he'd
25:38
just done that report and I said, well, what are you
25:41
thinking now? Because you wouldn't be here in
25:44
East Kent if they'd followed through on the recommendations
25:47
at Morecambe Bay. And that's the problem is we're
25:49
seeing what a very good reports into these scandals and then it
25:56
sort of seems to go into the ether now.
25:57
I'm sure there have been some improvements but because I am
26:01
still doing these stories, these heartbreaking stories, you know,
26:06
not enough is changing as we've agreed here today.
26:09
Will another rapid review help? I don't know.
26:12
Will an A public enquiry? That's one of the other calls.
26:17
Again, I don't know if it will help, but something needs to
26:20
happen that is bigger and more than has been than has been
26:24
recommended so far. Thank you all very much indeed
26:27
for your time. Kaylee and and Jeremy, thank you
26:30
for joining us. That's the forecast for today.
26:33
Until next time, bye bye.