We heard from the BBC news today that a report that they had finally gained access to, revealed a lack of trust and low staff morale contributing to a series of problems in maternity care at North Devon Health Care NHS Trust between 2013 and 2018. This resulted in 11 serious incidents. The BBC report is a dispiriting read. The report identified a lack of trust and respect between staff; senior midwifery anxiety that the quality of care was poor; and inaction at the Trust.
There were two elements in the BBC report that struck me as particularly significant. The first and by far the most important was a parent describing that she had blamed herself and had been “carrying guilt around” for a decade. This resonates strongly. We frequently meet with parents of children with profound disabilities as a result of poor obstetric who are filled with questions and self-doubt and have often been battling with social services to get appropriate provision for their child. They come to us with a heavy heart and needing answers to questions about why they are in the situation they are faced with.
It is deeply disappointing that, it seems in this Trust, some of the parents were not even aware of the outcome of the internal enquiries. That the parents of a child are excluded from the investigation process is unacceptable for two main reasons. Firstly they have a right to understand what has happened to their child. Secondly, and equally importantly, their personal narrative may well add important information that permits learning and prevention of future occurrences.
Which brings me to the second element that struck me when I read this particular report which states “In attempts to prevent the release of the full 2017 report, the Trust argued anonymity was required to ensure staff participation in future reviews”. I strongly refute this argument. There are very few doctors who would willingly collude with a cover up (and although my language is strong, that is what this appears to be). If handled appropriately, well supported early enquiries into adverse incidents can help ensure learning and de-stigmatise inevitable adverse incidents. Caring doctors who, almost without exception are doing their best, can return to giving front line treatment without the significant dent to morale that was reported in Devon.
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About the author
Kate Rohde is a Partner in the Clinical Negligence and Personal Injury department and an experienced specialist in clinical negligence claims of all types, often acting for bereaved families or on behalf of children and adults who have suffered permanent and profound injuries.