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"I haven't got this" (Universal Images Group via Getty Images)
Watching me treat a pregnant patient with a minor injury in A&E, one of my medical students asked me for some careers advice. She was most interested in obstetrics, she told me, but was worried about the recent controversies that had tarred the specialism. There had been a long, pitiful line of negligence claims against the NHS culminating, last week, in the Betsi Cadwaladr health board agreeding to pay £4m in compensation to the family of a baby who was left “severely disabled” by a caesarean section performed at Glan Clwyd Hospital in 2018.
The best advice I could offer that student was anecdotal. My time in obstetrics and gynaecology was over 20 years ago, but I remember very clearly walking into my first delivery room, taking a deep breath, and repeating to myself, silently, “I’ve got this, I’ve got this, I’ve got this”. At the critical moment, when the baby started to crown and, in an almost cosmic sense, explode into the earth’s atmosphere, I realised: “I have so not got this!”
I had been on the vascular ward where people had lost their limbs. I had taken patient histories only to return later to discover they had died. I thought I had seen everything. But nothing prepares you for O&G. When I was at medical school, students typically experienced a few days on a labour ward, and over a period of several weeks would be expected to assist in around a dozen deliveries. While this may not sound like a huge number, I was competing with eight or nine fellow students, each of whom had to get their dozen in. I was also up against a group of student midwives with their own quota. This hectic status quo, which at the last count oversaw 681,560 live births in the UK, accounts for a less than friendly level of competition among students, exacerbated by a culture of tribalism on maternity wards.
This internal politics put lives at risk. An obstetrician friend often talks of being sidelined or ignored by midwives, while midwives have complained to me of a hierarchy that seeks to undermine their independence. Throughout the country, the battle between doctors and midwives for “control” of the delivery room results in poor decision-making. Mediation is needed in severe cases, but senior hospital managers are often too busy watching their own backs to intervene. It’s a dynamic that causes injuries and fatalities.
When all goes to plan, the aftermath of childbirth should be joyful. Too often, it isn’t. Shortly after my baptism of fire, I was involved in the delivery of a child with foetal alcohol syndrome. I could see instantly from the child’s cataracts and cleft lip that there was a serious problem — but knew from my training that there was very little I could do to help. In this instance, the health service was in no way to blame. But there are times when the institution I’ve dedicated my working-life to does jeopardise the health, and futures, of our most vulnerable patients: newborn babies.
In September, an inquiry began into a hospital not far from where I work. Nottingham University Hospitals’s maternity unit is facing allegations that dozens of babies have died or been left with serious injuries after receiving inadequate care. NUH, which runs Nottingham’s City Hospital and Queen’s Medical Centre (QMC), has already paid out millions to the families of 30 babies who died and 46 infants who were left brain-damaged. It is also being prosecuted over the death of Wynter Sophia Andrews, which could have been prevented had she been delivered sooner. An inquest found she had died from hypoxic ischaemic encephalopathy — a loss of oxygen flow to the brain during delivery — after she was born by Caesarean section at the QMC in September 2019.
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SubscribeThis is unutterably depressing. And the worst of it is our leaders seem simply not to care.
My sense is that the UK’s leaders care about newborn babies, but the NHS is consuming a huge amount of the national budget and it’s not possible to continually provide more resources. I suspect a step toward solving the specific problem of inadequate care for newborns is to spend less on end of life care for the elderly. Yes, that will require some hard choices, but the pandemic prioritized the very old over everyone else, especially the young, and we now see the consequences of that decision.
“spend less on end of life care for the elderly.”
Where would you suggest?
Shrewsbury and Telford NHS Trust were failing in maternity care between 2000 and 2019. The pandemic was 2020 wasn’t it?
Agreed. The problem is that, outside of Unherd, nobody would dare to say what you have said.
I am old. The people around me are old. Quite a few of these people have abused their own bodies and continue to do so. The expectation is that any problems and the NHS will take care of everything.
I do have one caveat. There is a shift among young people towards veganism. What happens, 30 years from now, if all of the (older) young people start to suffer from unexpected illnesses because they have not looked after their bodies properly? Again, another set of young people will say that older people must make way for the young. And so on and so on. So, on the one hand you are right and on the other…..
So you and J Bryant seem to be suggesting that it’s an issue of money.
And the leftists here in America had the nerve to say the skeptics of socialized healthcare were lying when we claimed that the only way to reduce costs in a socialized system is by rationing care. Granny is a bad investment.
A
Which leaders?
There is a point where you have to stop blaming “leaders” and point fingers at reasonably well paid healthcare professionals who put personal interest, nepotism and politics above patients.
There are lots of countries that are awfully run. Though mostly dictatorships, that’s not the basic reason. The reason they are a mess is because ordinary people have lost their sense of morality and dignity.
Unfortunately the rot set in when nursing (including midwifery) demanded a degree, and thus put more emphasis on academic ability than compassionate care, excluding the less academic from a progressive career
As a parent I’ve seen maternity wards from the inside a few times and I’ve always found midwives to be excellent, doctors maybe less so.
My eldest was born in the early 1990s and my youngest in the mid 2000s, quite a big gap. One thing that struck me was that in the 90s the midwife was very attentive and spent a bit of time making notes; by the mid 2000s this had flipped and she spent a lot of time making notes, occasionally checking to see if my partner was okay. Not uncaring but very busy and I’m guessing not enjoying her work as much as her older colleagues may once have done. I’m guessing that trend has continued.
She may have been note taking to ensure that everything was written down so that she had proof of what went on – covering herself in the event of litigation.
Which also seems to be the way regular doctor visits are going, too.
I almost lost my daughter in law and granddaughter at East Kent. As she had three children without complications she opted for the then new birthing centre. She realised something was wrong, she was ignored, her husbands concerns dismissed offered no pain relief, told she didn’t need it! Finally the midwife called a doctor and she was rushed for an emergency c section. Fortunately they were both ok though my granddaughter had lapses of consciousness for a few years but seemed to outgrow it. The main problem seemed to be reluctance of midwives to call a doctor as if it was a competition. They were lucky.
According to the Royal College of Midwives there were 22391 Full time equivalent midwives in England in 2021. The ONS figure shows 624828 babies born in England and Wales last year. Even with higher figure including Welsh births this amounts to births per midwife of 27.9 per annum. I realise midwives have other duties on top of the labour ward but these figures don’t seem to indicate a shortage of midwives.
There are a small % of the NHS who are genuinely very overworked. And a lot of these are either very well paid senior doctors /surgeons or junior doctors on that track.
Most of the other staff appear to be working hard, but in a stereotypically government bureaucracy manner – inefficient, lots of time in paperwork or just sitting around, and little concern for the patients.
Had a few incidents with wife. Not to go into details, but the individuals were invariably nice and polite. As a system, impossible to get even vital post operative information on the phone, inhumane, utterly disorganised and wasteful.
My daughter is a trainee midwife coming to the end of her preceptorship.
She is not supposed to be included in the formal shift numbers, yet, because of short-staffing, she is.
This is unreasonably stressful for someone who is still officially a trainee and dangerous for patient care and oversight.
Tragic and so true – across the entire NHS
In the NHS, neglect of duty goes unpunished, with predictable, and lamentable, results.
The problem lies in the tension between providing medical care including O & G for the population of the UK where in the nature of things errors will inevitably be made in some individual cases and the legal right to compensation for individuals who have been affected by such errors.
In a system involving limited resources, and however lavishly resourced there must be limited resources, the cost of compensating the subjects of errors must draw resources away from providing resources to meet the needs of other patients. So the incentive for those involved in administering the system is likely to be to try to hush up and deny the individual errors where they can for the perfectly laudable motive of defending the funds to treat other patients. When an error can result in a £4 million drain on the Trust funds denial of error is bound to prevail where it can be supported. Interestingly in an NHS Resolution report 50% of settled cases in the period covered involved Administrative error.
Of course, a rational system would publicise and analyse every error to try to reduce their incidence and put in place systems to reduce them but the pressure of compensation militates against this so although some analysis and publication does occur it is clear that not enough occurs.
NHS Trusts pay into an insurance scheme, in pretty much the same way as third party car insurance is intended to compemsate victims of negligence. The annual premiums are themselves quite swingeing, and ever-increasing. I don’t have the figures, but Trusts also employ legal advisors at no doubt significant expense to try to minimise their liability.
As Emma points out, accidents will happen and human error will remain a factor in all healthcare interventions. There are ways and means of building in greater safety through real-time checks and audit (part of the much-derided bureaucracy but also much misunderstood) which seeks to root out systemic failings before they result in the types of devastation described in the article. Its obviously not working well enough in too many hospitals.
Following a previous article hy Emma, i described on here how many NHS employees (from my own experience of 35 years in the service) worked in what might best be described as a dilatory way and was called a p*ick by one respondent for pointing it out. They’re not the majority of course, but they do bring the system down to their level. Emma’s article highlights the truth – of internecine warfare between Consultant firms, different professions competing for the upper hand, staff too busy watching their own backs to see what’s in front of them – vulnerable members of the public expecting a high standard of both medical and human care.
Most patients, and expectant mums, will receive a high standard of care but the systemic pressures allied to unsackable problem staff results in far too much heartbreak to be sustainable under the current arrangements. Instead of Trusts using insurance schemes as a sop to compensate the uncompensatable, insurance should become an up-front accepted part of the healthcare provision, on a model based upon countries such as Australia where they simply do things better, unburdened by the political iconography.
Thank you for clarifying the position. I was unaware exactly how the compensation was handled but as you say the premiums are swingeing and ever increasing I presume they are also related to the individual Trust’s record.
My wife suffered pre-eclampsia with our first child so was potentially at severe risk and I spent some time catching her vomit during the birthing process but I do recall that someone had left a syringe in her bed that nearly pierced her leg so clearly there had been a failure of process. My wife was actually reassured by the fact that the doctor in charge of the ward picked up on and criticised the behaviour of a nurse involving another piece of neglect whose nature I now can’t recall.
The most unsatisfactory experience I saw involved my mother-in-law in a nurse-led post-operative recovery ward involving a catalogue of errors and neglects where the sister in charge was both arrogant and ignorant. As you say too much time seemed to be spent there recording and gossiping. The most diligent nurses seemed to come from abroad.
I am interested to hear you contrast the UK system with that of Australia. What are the features that might usefully be adopted from Australia? One of the changes I have seen in my lifetime in one type of marine insurance has been the change from the insurer assuming the shipowner knew his business best to the insurer highlighting to the industry the causes of avoidable accidents so that their incidence could be reduced. I presume a similar process is involved in well run hospitals and Trusts.
Trusts can have their insurance premiums reduced by demonstrating effective audit processes with actual examples where patient care has been improved through the analysis of negative events, preferably before they cause harm – for instance, surgeons leaving instruments in the patient after closing them up. That’s an extreme example, but that’s why operating theatres (should) have stringent instrument counting procedures in place. A less extreme example would be the giving of pre-operative antibiotics to help prevent infection. Or, the recording of a patient’s temperature / blood pressure at regular intervals to check for signs of a deterioration in condition.
The recording of all these things is essential for the audit trail to be followed, hence why it may now appear that clinical staff spend more time doing so. This process may well be computerised, for easier analysis.
Patients may be placed on what’s known as a Care Pathway, with predetermined documentation which flags up the steps necessary to maximise patient safety and a successful outcome. This should act as a check against missing anything vital, but staff pressures then come into the reckoning. It’s as complex as it sounds, and then add on the professional rivalries! The example you quote of insurance against shipping accidents, whilst not downplaying the dangers and intricacies of navigating huge vessels in uncertain seas/channels, is almost certainly less complex.
Edit: and just to add, although the compensation payouts don’t come from the individual Trust budgets, they do of course come from the public purse so the overall amount available to spend on patient care is reduced. Plus, the public (rightly or wrongly) are now much more litigious than they used to be. In the cases quoted in the article, absolutely rightly. But then, the “lessons learned” mantra is trotted out, and they very rarely are; or only for as long as those who might learn the lessons are in the workplace.
Pregnancy and childbirth aren’t illnesses. I and my siblings were all born at home
But they can provoke emergencies. Our first child was a footling breech; we were very pleased we’d chosen to have the birth in hospital rather than at home. Mind you, it was a very good unit in a specialist hospital.
Yes. But hard cases make bad law.
I’m just pleased my wife and baby daughter didn’t die at home.
So sad and strange to hear about Shrewsbury. Shrewsbury was the 3rd hospital we had children at and we felt it was great. At least in comparison to the others where we lost twins and had serious shortcomings with the other 2 children’s births.
In fact we felt it was so much better that we had no doubt about going back there for the fourth child. We could see and feel that it deserved its great reputation and felt that this was due to its lead Dr Mohajer and the environment she created. We still think of her very positively.
Obviously others had a different experience but I cannot help but wonder and believe that if the other hospitals had an Ockenden type investigation they would come out even worse.
I seem to recall this law of Suppression throughout the NHS was why black West Indian nurses in the 1960’s,opted to be in the Maternity Wards as it wasn’t polluted by clinical biases. Carl Lammy
I
Another avoidable Healthcare crisis?