The Morecambe Bay Investigation report was published on 3rd March. Myself and other families gave our reaction here.

 

After what has undoubtedly been a really difficult 6 years since losing Josh, I feel (and I know other families feel the same), that finally we have a report that reflects the full truth regarding events at Furness General Hospital (FGH). It took a few days for the report to sink in and then, being completely honest, I’ve been surprised at how I’ve felt in the days since. Whilst I’ve certainly felt a sense of relief and vindication, I’ve also felt deeply sad and frustrated. The way organisations like the Health Service Ombudsman have responded has undoubtedly not helped, but I suppose more fundamentally, now we’ve reached some sort of ‘end point’ my family and I are still left without Joshua. The scale of how preventable and unnecessary Joshua’s death was is now more clear than ever before. This only adds to the sense of sadness, that nothing can bring this little boy back.

 


 

The reality is that nothing can now undo what happened. Myself and other families will have to come terms with that. This is painful and hard.

 

The only ‘remedy’ myself and other families now have is to take comfort from the changes the Kirkup report will now hopefully bring about. Looking on the positive side, this week I met with Jackie Daniel (Trust CEO) and Pearse Butler (the recently appointed new Trust Chair).  I couldn’t help but feel impressed by their openness and sincerity. I can’t speak on behalf of other families, but my sense is that the Trust has now fully accepted the report and are determined to do everything possible to learn and continue to improve in response. 

 

In this blog I also want to talk about the response to the Kirkup report from another important group, midwives and midwifery leaders. Before doing so, I wanted to emphasise that I have a great deal of respect for midwives. I think the vast majority of midwives are incredibly caring and hardworking people who go to work with a passion to bring new life into the world and work in the best interests of mothers and babies.

 

However, I also believe that there are some areas in which improvements are needed in the way maternity care in England is currently delivered. Anyone who follows me on Twitter will know that one of my biggest areas of concern is around the ideology of ‘normal birth’. We all form views and opinions based on our experiences. In the very early days following Joshua’s death and after reading about other tragic cases that happened at FGH, I formed a strong view that an over emphasis on achieving ‘normality’ was a factor in some of the events that occurred.  The Kirkup report fully vindicated my views on this, concluding.

 

“…midwifery care in the unit became strongly influenced by a small number of dominant individuals whose over-zealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care… We…heard distressing accounts of middle-grade obstetricians being strongly discouraged from intervening (or even assessing patients) when it was clear that problems had developed in labour that required obstetric care. We heard that some midwives would “keep other people away, ‘well, we don’t need to tell the doctors, we don’t need to tell our colleagues, we don’t need to tell anybody else that this woman is in the unit, because she’s normal”. Over time, we believe that these incorrect and damaging practices spread to other midwives in the unit, probably quite widely.”

I support Dr Kirkup’s view that “…natural childbirth is a beneficial and worthwhile objective in women at low risk of obstetric complication…”. However, since taking an interest in these issues in recent years, I’ve been really concerned at what I think has become a lack of balance by some in the debate.

For example, I’ve written before about attempts from some midwifery leaders to play down / undermine the risk associated with childbirth. This blog gives the clearest example of this. Surely it’s important not to overstate or understate risks, but to give true and accurate information to people to help them make informed choices?

I’ve also found that even raising the subject of risk in childbirth can result in dismissive responses on social media.

Earlier this week I participated in a #WeMidwives chat during which I raised this letter from a Doctor which was recently published in a national paper.

In response I was accused of ‘bashing MWs’ and ‘retrospective negativity’.

I don’t think either of these comments are fair. The Doctor who wrote this letter states that he reviews notes ‘all over Britain of babies who may have suffered severe brain damage or death at birth’. He says ‘…a recurring pattern is delay by midwives in calling for medical assistance.’ He also refers to the Kirkup report which was published only two weeks ago.  How can reflecting on these issues be ‘retrospective negativity’?

I could also not help but feel disheartened by another online piece I came across this week in which a number of midwifery leaders give their thoughts on the Kirkup report.

Amongst them was this comment.

This concerns me for a number of reasons. Firstly, the notion that ‘protecting normal birth’ is the core function of a midwife is one I really struggle with. Surely the core function of a midwife is to protect mothers and babies? This author also states ‘I have honestly never a met a midwife who compromised safety in the pursuit of ‘normal birth’. So is what happened at Furness General Hospital really just a unique, one off situation?

Certainly other comments suggest so.

But how can midwifery leaders like this be so sure? Should we really be so ready to dismiss concerns like those of Dr Essex so readily? What does other evidence tell us about why avoidable outcomes during childbirth tragically continue to occur?

This is something I have also written about in the past.

Even a quick review of the evidence suggests that the type of problems that occurred at FGH are far from unique. In 2013, NHS Cumbria published an inquiry into all perinatal deaths that occurred county wide in 2010.

 In this single year, the report found 38 perinatal deaths that had avoidable factors or elements of substandard care. Fifteen of these 38 cases were identified as having avoidable factors in relation to referral to a specialist. The report states.

 

“…many of these were a failure by the midwife to refer to an obstetrician in time for an intervention to be made.”

These comments closely echo the findings of Dr Kirkup’s report.

What can we learn from tragic stories we continue to read about in the media like these?

http://www.bbc.co.uk/news/uk-england-essex-30955936

http://www.telegraph.co.uk/news/health/news/9758307/Baby-died-after-midwives-failed-to-call-for-help-during-labour.html

http://www.hulldailymail.co.uk/Mum-awarded-25-000-midwives-8217-mistakes-led/story-26041836-detail/story.html

It is my strong view that it would be a tragic missed opportunity if the general response to Kirkup from the midwifery profession as a whole was to dismiss what happened as a local failure, the lessons from which thought not to be applicable to the wider NHS.

I hope that there will be much more open debate about Kirkup in the future, involving both midwives and doctors. Of course, it remains important that maternity services function to avoid unnecessary interventions, but the post Kirkup debate must surely include a real focus on how best to ensure midwives work to protect mothers and babies by making appropriate referrals to obstetric colleagues when necessary. We need to be honest about the risks of childbirth and ensure that when mistakes do occur, proper learning takes place.

 –

Whilst we must have a culture that never seeks to blame or punish individuals for genuine mistakes, we must also strive towards a culture that doesn’t tolerate covering up and which holds people to account for recklessness.

 –

The planned changes to midwifery supervision such that the current tier of self regulation that failed so badly at FGH is removed, together with the forthcoming national review of maternity services by NHS England are real opportunities to make lasting changes to improve the safety of maternity care across the system.

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I hope this opportunity is embraced by all and that the Kirkup report will one day be looked back on as a real turning point for the safety of midwifery care in the NHS.




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3 thoughts on “Responses to Kirkup  – 20th March 2015 

  1. Liz Piercy

    You have fought such a long battle to get to the truth and great determination that improvements to care are made as a result. It is a real tribute to your son.

    I think it is a good idea to turn your back on the PHSO and let their actions speak for themselves.

    Health care has improved greatly as it has become firmly evidence based, and I think evidence-based maternity care is the way forward. There is no room for ideologies or beliefs when the life and health of a mother and baby are at stake.

    I don’t agree that pregnant women all fear technology or hospital units. Many find it reassuring that the back up is there if needed.

    I really hope that all midwives and obstetricians will embrace working together to reduce the perinatal mortality rate and terribly sad outcomes.

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  2. Angela Clipstone

    We hope so much this is a turning point. Recently we laid our darling baby grandson to rest following a catastrophic delivery with many opportunities missed to save him. If the smallest proportion of the massive effort given to save him after the delivery had been directed at the birth I am convinced the outcome could have been so different. Thank you from us all for your persistence to make a safer NHS for us all. I salute you, you are an inspiration.

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  3. Rich

    Great work, great decision re Phso. Sadly I do not have the choice. Despite ongoing failing in end of life care in hospitals for years, as recent health committee report shows, no In depth inquiry planned or possible so PHSO is my only source for investigation to learn lessons of avoidably painful death. And Cqc despite identifying the same failings 30 months on say I have to await the Phso,despite phso being nine months in to its third investigation and nine months in to their review of previous admitted failings without any result. I have also gained much evidence on a variety of issues in my complex complaint leading to a nhs patient safety alert, failing to respond to equipment failings subject to a patient safety alert, an expert report showing a model of expert service not fit for purpose, ongoing medical risk due to under resourced services and more . yet neither cqc ccg healthwatch nhs England can do any more…all effectively await the third cqc inspection who knows when, soon to be four years on, to see any continuing end of life care failings ( I have no evidence of a serious action plan of trust) or left to await the Phso and a retrospective report. Shameful, inadequate, especially given half a million die a year and end of life care services are so variable and in too many cases seriously and unchangingly inadequate . Can cqc safety advisers help the Phso achieve a proper investigation more quickly or initiate something given this excessive stressful time?. My 87 year old mother suffered unbearably bad death.there has been no serious remedy or serious investigation. A crime surely in this post mid staffs and post morecambe bay world?

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