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‘Lessons not being learned’ from failures in maternity services

‘Lessons not being learned’ from failures in maternity services

New parents are being ‘failed’ by maternity services across the country, with repeated mistakes putting women and babies at risk, the parliamentary health watchdog has warned.

A new report from the Parliamentary and Health Services Ombudsman (PHSO) has stressed ‘lessons are not being learned’ in maternity services despite several major reviews.

While it recognised those working in maternity services wanted to provide high quality care, it stressed that ‘culture, systems and processes can get in the way of achieving that goal’.

Sharing the stories of women who have been let down by maternity services, the Ombudsman said it hoped to make clear the impact of continued ‘serious failings’ in the care of new and expectant parents.

Families informing the PHSO said they ‘want what happened to them to matter’ and to ‘make sure voices like theirs are listened to and heard’.

One story shared in the report was from Patricia Michael who experienced bleeding during her pregnancy but was not given an ultrasound to investigate this.

When she had her baby, her placenta did not deliver naturally as it should. The placenta was removed manually, not in an operating theatre under anaesthetic, which meant a large part of it remained.

This led to Ms Michael being in pain and needing two more operations to remove the rest of the placenta.

Staff also did not explain or provide Ms Michael with information about a haematoma on her baby’s head before she left the hospital which caused her distress.

Ms Michael said: ‘What happened to me should never be allowed to happen to anyone else. It was a traumatic experience that affected me deeply and still does. All women should be able to trust the care they’re receiving is the best and that everything is being done as it should be.’

The report flagged ‘too many families still face care that puts the safety and wellbeing of women and babies at risk’.

It also pointed to the latest national maternity survey which shows a ‘decline in people’s positive experiences of using maternity services’ and that areas needing improvement included ‘staff availability, confidence and trust, and communications and interactions with patients’

The Ombudsman said it appreciated the ‘hard work of healthcare staff’ trying to improve maternity services, ‘especially when the NHS is under such significant pressure’.

‘We recognise that people working in maternity services want to provide high-quality care,’ the report added.

‘Culture, systems and processes can get in the way of achieving that goal.’

Parliamentary and Health Service Ombudsman Rob Behrens said cases found in its latest report were ‘extremely distressing’.

‘People should be able to trust that the care they receive during what should be one of the happiest times of their lives will be safe, effective, and compassionate,’ he added.

‘Expectant and new parents are being failed right across the country, and very often in the same ways.’

The report follows several high-profile reviews that have revealed significant issues with the care of mothers during and after birth in a number of trusts across the NHS.

Both the Ockenden Review and review into the East Kent Hospitals University NHS Trust identified a number of areas for action to improve outcomes within the NHS.

However, the Ombudsman said its latest report showed the same failures are still being repeated across the health service.

‘The fact that we are still seeing the same mistakes over and over again shows that lessons are not being learned,’ said Mr Behrens.

‘This is unacceptable. There needs to be significant improvements and change.’

The report also includes information on how to make a complaint to the Ombudsman for those who may experience poor maternity care.

Mr Behrens added: ‘Everyone has the right to complain if they receive poor care. I want to assure patients and families who have experienced something like this that their voice matters.’

A recent warning from Healthwatch England claimed new mothers were being failed at their six-week postnatal check. The patient organisation said not all practices were complying with the contractual requirement to provide the postnatal review.




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