Avoidable baby deaths are ‘a badge of shame’ on the NHS as expert warns bereaved families have to report maternity blunders as watchdogs and hospitals are unable to spot failings
Bereaved families are having to report maternity blunders because watchdogs and hospitals are unable to spot failings, an expert has warned.
Bill Kirkup said avoidable deaths were ‘a badge of shame’ but would continue without urgent change.
Eight years on from his report into the Morecambe Bay maternity scandal, he said the failure of officials to act had needlessly cost more lives.
‘I am very disappointed – and surprised – that we’re still where we are,’ he said.
‘That’s a terrible badge of shame for the health service that it takes families to come and tell us what’s wrong.
Bill Kirkup said avoidable deaths were ‘a badge of shame’ but would continue without urgent change. Eight years on from his report into the Morecambe Bay maternity scandal , he said the failure of officials to act had needlessly cost more lives
‘I am very disappointed – and surprised – that we’re still where we are,’ Bill Kirkup (pictured) said. ‘That’s a terrible badge of shame for the health service that it takes families to come and tell us what’s wrong’
‘Yet just about every tragedy that I’ve ever been involved with investigating has come to light when there’s a group of families who say “You’ve got a problem here”.
‘People are lying, they’re not being open and they’re concealing what’s happening.
‘If we can’t bring this change, I’m not confident that there won’t be another East Kent, Morecambe Bay or Nottingham, somewhere else.’
Dr Kirkup said cover-ups, toothless regulators and the absence of proper scrutiny of maternity outcomes meant picking the next scandal was like ‘finding a needle in a haystack’.
He said an accountability law was needed to put a duty on public bodies to tackle, rather than conceal, potential issues. Coroners should also be given jurisdiction over stillbirths, allowing failures to be fully investigated, he added.
Dr Kirkup led the inquiry into East Kent maternity services last year and was involved in both the Hillsborough and Jimmy Savile investigations.
His inquiry into the University Hospitals of Morecambe Bay NHS Trust found 20 major failures from 2004 to 2013 at Furness General. These led to the unnecessary deaths of 11 babies and a mother.
He had hoped his 44 recommendations would bring meaningful change to maternity care but admitted they had failed to stop the ‘recurring cycle of catastrophes happening in a unit sooner or later’.
The Government this week published its initial response to the East Kent maternity inquiry, in which Dr Kirkup and his team concluded that up to 45 babies could have lived with better care.
Regulators have painted a worsening picture of maternity care in England, with the most recent Care Quality Commission report finding more than half of services failed to meet safety standards.
Almost a third of maternity units were judged to require improvement with 6 per cent inadequate.
Just 4 per cent were judged to be outstanding and the remainder good. Experts say this does not paint the full picture, with East Kent rated as ‘good’ for aspects of its care during periods covered by the damning inquiry.
NHS England is this month expected to publish a single, maternity delivery plan, designed to simplify safety improvement.
James Titcombe, whose son Joshua died of sepsis nine days after his birth at Furness in 2008, said he hoped it would ‘finally be the reset moment’.
The patient safety campaigner added: ‘A lot of the recommendations from the Morecambe Bay report have not happened and progress has been much too slow and fragmented.
‘The latest ONS data shows stillbirths and neonatal deaths have actually increased, rather than previous trends of falling, so all in all, it’s a pretty depressing picture.’
Jacqueline Dunkley-Bent, chief midwifery officer for NHS England, said: ‘We will continue to work with NHS trusts in England, with the Government and our partners to make the necessary changes and implement the recommendations from Bill Kirkup’s review.’
How errors cost life of my daughter
A mother whose baby died after her heartbeat was mistaken for her daughter’s says she would still be alive if medics had learned from earlier mistakes.
Emily Barley, 34, said she was dismissed as ‘a dramatic first-time mum’ when she raised concerns about her labour.
Staff at Barnsley Hospital ‘ignored alarm bells’ and refused to send her for a caesarean.
Her daughter Beatrice died during labour last May with subsequent inquiries revealing she was one of 13 maternity investigations at the trust since 2019.
Emily Barley (pictured), 34, said she was dismissed as ‘a dramatic first-time mum’ when she raised concerns about her labour
Miss Barley said her ‘world had been destroyed’ by mistakes similar to those in previous tragedies at the hospital. Monitoring had shown up decelerations in Beatrice’s heartbeat, a sign the baby could have been in trouble.
And tests found meconium in the amniotic fluid, another pointer that a baby is in distress. Staff then mixed up the heartbeats.
‘They didn’t act when monitoring showed when Beatrice was in trouble. If they had, I would still have my beautiful daughter today,’ said Miss Barley.
Dr Richard Jenkins, Barnsley Hospital’s chief executive, said it recognised the tragic event should not have happened and had apologised to Miss Barley.