It is hard enough to come to terms with the death of a child; it is even harder when you know it could have been prevented.
Preventing stillbirth and loss in pregnancy and supporting families in bereavement is something I feel passionately about both personally and professionally.
It was at my 20-week scan, that my husband and I received the terrible news that our baby, Lily, had an extremely severe form of spina bifida. Two days later I was induced and delivered a tiny fair-haired, beautiful, sleeping girl - I held her, kissed her, and told her how much she was loved. Then I let her go.
This inspired my mission to help others, and I have been pleased to co-chair the parliamentary group on baby loss to help other people in our situation. During this time, I have spoken to countless families about their own experiences. All these families have important insights into the care system, but these are often unheard by professionals because consistent processes don’t seek them out.
Last week, the long-awaited East-Kent maternity report was published – an important moment for the families impacted by failings at the Trust during 11 years from 2009.
The independent review, commissioned by the Department of Health and Social Care, highlights several areas of poor care which had a devastating impact on families, many of whom, rather than being listened to, were treated dismissively, contemptuously and without a desire for understanding. Failures include a lack of teamwork across the Trust’s maternity services, a lack of professionalism and compassion leading to women being blamed, and failures in regulation that failed to identify shortcomings early enough.
Tragically, the report found that had the East Kent Hospitals Trust met nationally set standards, the outcome of baby deaths could have been different in 45 out of 65 cases.
The report is not the first to highlight failures in listening to families as a key issue. Earlier this year, an independent review into maternity services at the Shrewsbury and Telford Hospitals NHS Trust, led by Donna Ockenden, also found serious failings in maternity services. Ms Ockenden stated: “The one issue that stands out above everything else was a failure to listen to families.”
The report highlighted issues with families getting the trust structure to listen, with examples of dismissive letters and a culture of ‘this is your fault’ to the parents - 'if you hadn't done X, your baby may have lived'. Several parents told Ms Ockenden that many mothers and fathers have carried that guilt for years. From my conversations with parents, it is clear this is one of the most difficult emotions to overcome. No parent should ever be blamed when things go wrong in the care of their children.
The Royal Cornwall Hospitals NHS Trust in my constituency serves as a shining example of how improvements can be made. The entire bereavement midwifery team at Treliske are outstanding, and I continue to be in awe of our local team. They do such a difficult job while supporting families at their lowest ebb and continuing to take special care of babies after they have died.
Their maternity team has made many improvements over the past 4 years including leadership, safety, and patient experience. Relationships within the maternity team and with external agencies have been strengthened, with the care and experience of birthing families at the heart of everything they do.
The Treliske team can also be commended for making progress against the 10 Safety Standards for the Clinical Negligence Scheme for Trusts and focusing on implementing the recommendations from the Ockenden Review. As a result, the trust ranks third out of 66 Trusts in last year’s CQC NHS Maternity Survey. I hope that Trusts across the country can learn from their successes. However, there is still improvements to be made, and I will be working locally to promote safer maternity care, including investment in staffing.
The Government also must play its role. It is right that the health department has recently established the Independent Working Group alongside NHS England, chaired by the Royal College of Midwives and Royal College of Obstetricians and Gynaecologists. This will guide the implementation and next steps of the recommendations from the Ockenden Report and the East Kent Report.
The group has met twice to date, and I am pleased the next meeting will focus on reviewing the recommendations for the East-Kent Report. It is also reassuring that in March 2022, NHS England announced a £127 million funding boost for maternity services across England that will help ensure safer and more personalised care for women and their babies.
The Ockenden and East-Kent reports show that parents’ voices are too often not listened to. We must all hope that these reports help change the culture that has silenced so many bereaved parents and prevented lessons from being learned. Only then can we prevent stillbirth and loss in pregnancy wherever possible.
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