Devastation of parents led to believe they're at fault when a baby dies
The Guardian recently ran a heartbreaking feature highlighting the ongoing and catastrophic situation around NHS maternity services, focusing on the parents of a baby girl who died in the Royal Hampshire county hospital in Winchester in 2019.
The subsequent HSIB report into baby Norah's death contained the line: '“An upper airway event (such as occlusion of the baby’s airway during skin-to-skin) may have contributed to the baby’s collapse,” suggesting the mother might have smothered her daughter.
Unsurprisingly, this poor woman spent the next four years in agony, despite the report also identifying failings in Norah’s care which likely caused her death, rather than the way her mother held her.
The unit was identified as short-staffed. Equipment was missing or didn’t work properly. Most importantly, Norah’s doctor didn’t understand the significance of her having different oxygen saturations (SATs) in her hand and foot, which indicated a congenital heart condition.
The HSIB investigators concluded that baby Norah should have been referred to a more senior doctor for review. Had this happened, she might have lived. But despite multiple signs that Norah was unwell, the HSIB led her mother to believe that she had possibly inadvertently killed her daughter.
The NHS is a behemoth and when something goes wrong, getting to the truth – and identifying accountability - is not simple.
Ten years ago, a duty of candour became a legal duty within the NHS requiring openness with patients. This is denied to far too many of our clients, bringing untold and prolonged unhappiness to entire families.
Clients are often not given copies of internal investigation reports, incomplete accounts of treatment are recorded, and an obsession remains with optimal reputational management at the cost of patient wellbeing.
The cost of not being honest was very clear in this article – Norah's mother contemplated killing herself multiple times. Openness with patients, explaining where the errors in care occurred, owning these errors and correcting them is how we move forward into safer care, allowing harmed patients to heal.
Initiatives such as Dr Bill Kirkup's ‘Reading the Signals’ and a new recruitment plan are all part of the programme to improve maternity care, but being open about causes of failures in the first place should underpin any programme to drive improved safety and patient care.