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‘Blame culture’ in maternity safety failures prevents lessons being learnt, says Committee

6 July 2021

A wide-ranging report by the Health and Social Care Committee on maternity safety in England finds that improvements in maternity services have been too slow, with the CQC’s Chief Inspector of Hospitals reporting evidence of a ‘defensive culture’, ‘dysfunctional teams’ and ‘safety lessons not learned’. Professor Ted Baker told the inquiry that more than a third of CQC ratings for maternity services identified requirements to improve safety, larger than in any other specialty. MPs recommend urgent action to address staffing shortfalls in maternity services, with staffing numbers identified as the first and foremost essential building block in providing safe care.

The Committee is also publishing a report it commissioned from an Expert Panel it set up to evaluate Government progress on delivering four commitments on maternity services. It concluded that the Government’s overall progress to achieve key commitments in maternity services ‘requires improvement’. Further CQC-style ratings are awarded individually against progress in the four key areas: maternity safety; continuity of carer; personalised care; and safe staffing.

Health and Social Care Committee Chair Rt Hon Jeremy Hunt said:

“Although the majority of NHS births are totally safe, failings in maternity services can have a devastating outcome for the families involved. Despite a number of high-profile incidents, improvements in maternity safety are still not happening quickly enough. Although the NHS deserves credit for reducing baby deaths and stillbirths significantly, around 1,000 more babies would live every year if our maternity services were as safe as Sweden.

“Our biggest concerns were around staffing and culture: staffing levels have now started to improve but we found a persisting ‘culture of blame’ when things go wrong which not only prevents people admitting that mistakes were made, but crucially, prevents anyone learning from them.

“Our independent expert panel gave an overall verdict of ‘requires improvement’ which sends a strong message that the Government and the NHS need to redouble their efforts ahead of the Ockenden report into Shrewsbury and Telford and the Kirkup report into East Kent. Nothing less is owed to the families for whom a birth was not the joyous occasion they had the right to expect.”

Professor Dame Jane Dacre, Chair of the Health and Social Care Committee’s Expert Panel, said:

“This is the first evaluation of its kind, commissioned by the Health and Social Care Committee and carried out independently by a panel of experts. Using a CQC-style scoring system, we have rated the Government’s overall progress on its maternity services’ targets as ‘requires improvement’.

“Our Expert Panel report covers in greater detail how far the Government’s maternity commitments have been achieved in key areas. Three commitments have been rated as ‘requires improvement’ – maternity safety, continuity of carer, and safe staffing – while a rating of ‘inadequate’ has been given to the commitment to provide all women with a personalised care and support plan.

“We’ve also found persistent health inequalities experienced by women and babies from disadvantaged groups, with poorer outcomes across all of the commitments we considered.

“However, underpinning all this are workforce issues. Maternity services must have the right number of staff, in the right place, at the right time and with the right skills – without that progress will stall.”

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