AND SO IT GOES ON AND ON AND ON FOR DECADES. THE EVERGLOW CAMPAIGN PRESENTED EAST KENT CCG WITH THESE SAME COMPLAINTS AND MANY OTHERS IN 2018, IF YOU CAN BEAR TO ….READ ON………
IEA= Immediate and essential actions
The impact of death or serious health complications suffered as a result of maternity care cannot be underestimated. The impact on the lives of families and loved ones is profound and permanent.
The families who have bravely contributed to this review know all too well the devastation which follows such events……….they want what happened to them to matter, and to ensure that, in future, voices such as their own are listened to and heard………to try to ensure that what happened to them will not happen to others in future………..
The accounts of families involved ……..put a spotlight on this service, but also on other maternity services across England, as can be seen by recent reports of concerns in a number of other trusts. That is why this report aims …………. to provide IEAs for all maternity services across England.
That spotlight can feel harsh to staff on the front line doing their very best in what are often extremely challenging circumstances. As a multi-professional clinical review team, largely made up of midwives and doctors currently working on a daily basis in NHS maternity services across England, we understand that.
….Where investigations took place, there was a lack of oversight by the trust board. Unfortunately, the review believes this has persisted in some incident investigations as late as 2018 to 2019 considered as part of this review.
This meant that consistently, throughout the review period, lessons were not learned, mistakes in care were repeated, and the safety of mothers and babies was unnecessarily compromised as a result. There were a number of external reviews carried out by external bodies, including local clinical commissioning groups and the Care Quality Commission, during the last decade. The review team is concerned that some of the findings from these reviews gave false reassurance about maternity services at the trust, despite repeated concerns being raised by families. It is the review team’s view that opportunities were lost to have improved maternity services at the trust sooner………
In addition, this workforce plan must also focus on significantly reducing the attrition of midwives and doctors, since increases in workforce numbers are of limited use if those already within the maternity workforce continue to leave.
…A board member told the review team that: there seemed to be a number of political issues making reform of services difficult……
….One staff member said to the review team:
People just didn’t do anything… and there just wasn’t a culture of accountability for completion…..
….In late 2021, the review team also spoke to some senior staff of the CCGs in post between the years 2013 to 2020.
We were told that the CCGs did have concerns about maternity services at the time, and were aware of the local press reports and family concerns. The CCGs had concerns about the length of time that serious incidents took to be reported and we were told by a contributor that: reviews of serious incidents seemed to take a long, long time to happen and there was an impression of evasiveness around how the learning from those reviews was shared.
The same contributor told the review team that the CCG did have meetings with the maternity service representatives from the trust, but were assured that “things were improving” and were told that the CCGs were in any event “limited in their power to change things for the better….
…….However, we are aware that similar problems may occur in other trusts across England and, therefore, these actions must be implemented widely in all maternity services.”……
This review is supporting and endorsing the latest Health and Social Care Committee report – A REMINDER THAT THE HEALTH AND SOCIAL CARE DEPT.,HAVE BLOCKED OUR CAMPAIGNS’ COMMUNICATONS