With the revelation that a “toxic culture” led to the deaths of mothers and babies at the Shrewsbury and Telford Hospital NHS Trust, patient safety in maternity services is once again in the spotlight.

A review at Shrewsbury and Telford was announced in 2017, just two years after the publication of the Kirkup investigation into similar failings in maternity and neonatal services at the Morecambe Bay Trust. During the course of the review (which has been extended as more families have come forward) news has emerged of yet more avoidable harm in maternity services at Cwm Taf.

Different times, different places, different providers. But a common factor throughout is a failure to take seriously the concerns raised by women and families.

At Morecambe Bay, “The treatment of complainants [included] defensive “closed” responses, delayed replies, and provision of information that complainants did not find to be accurate.” [1]

At Cwm Taf, “Women repeatedly stated they were not listened to and their concerns were not taken seriously or valued.” [2]

At Shrewsbury and Telford, according to reporter Shaun Lintern, who has seen a leaked report, there is “A long term lack of transparency, honesty, and communication with families when things go wrong.” [3]

Clearly, the failure to listen to patients and bereaved relatives is not unique to the Shrewsbury and Telford Trust. And neither is it unique to maternity services. Similar observations can be found in the Francis report on the Mid Staffordshire disaster, and in avoidable deaths reports from Southern Health, Gosport, and the Northern Ireland Hyponatraemia inquiry. They crop up again in Ombudsman reports such as Learning from Mistakes and Ignoring the Alarms.

The inquiries listed above come to a total of nine over a period of seven years. These are not occasional mishaps. There is a pattern.

There will always be a risk of safety errors occurring in the high pressure and unpredictable environment of acute care. So errors need to be examined and explained. Instead we find that over and over again, when patients die avoidable deaths, their shocked and grieving relatives are locked out of investigations, refused access to information, and denied justice.

Why does this keep happening?

Ted Baker, the Chief Inspector of Hospitals suggests why. He recently hit the nail on the head when he described it as a cultural problem. Commenting on the slow uptake of Learning from Deaths guidance, he said, “we are still seeing the same issues persist in some NHS trusts…Issues such as fear of engaging with bereaved families, lack of staff training, and concerns about repercussions on professional careers, suggest that problems with the culture of organisations may be holding people back from making the progress needed”. [4]

The reference to organisational culture is important. But it is not enough to set up inquiry after inquiry, looking at each culpable organisation in turn.

We need to recognise that the culture of any one organisation does not arise in isolation. It is part of, and to some extent derives from, an overarching NHS culture. And the national culture does not always seem to treat patient feedback as a valued resource for learning. Evidence of this includes the following:

We tolerate the use of dismissive language . Patient feedback is routinely referred to as “anecdotal evidence”. That diminishes patient experience, and robs it of its value for learning.

We are comfortable with a double standard in use of evidence . Medical evidence is cherished, preserved and used. Patient experience evidence is treated as disposable. Both sets of evidence should be accorded equal value.

We are content to weaken the independent patient voice. Healthwatch, set up in the wake of the Francis Inquiry, was meant to be a strengthened successor to the Local Involvement Networks. But Healthwatch funding has fallen by over a third since 2013 .

So what is to be done?

Perhaps the most important thing we can do is to inject a sense of urgency. With more than one inquiry per year uncovering what Francis described as “callous indifference” towards patients and those close to them, we cannot afford to dawdle. [5]

We can make a start straight away by tackling the cultural issues referred to above. The term “anecdotal evidence” must be challenged wherever it is used. Directors of Nursing could lead on this. Patient experience evidence should be embedded in professional training, clinical guidelines and practice protocols—just as medical evidence is. NHS England has the Patient Experience Library at its disposal—it just needs to start using it. Healthwatch funding should be restored to its original 2013 level. That is a job for the Secretary of State.

None of this would be hard to do. But it all needs explicit commitment from people in leadership positions.

Changing the culture of patient experience work will not guarantee an end to avoidable deaths. But it will give patients a better chance of being heard. That will give providers a better chance of picking up what Francis called “the early warning signs that something requires correction”. [6] And it will give all of us a better chance of seeing an end to this distressing and repetitive pattern of bereavement, cover-up, and official inquiry.

Miles Sibley is a Director for the Patient Experience Library—the national evidence base on patient experience and involvement. www.patientlibrary.net



Competing interests: MS is a Director of the Patient Experience Library. The library is entirely self-financing, it receives no grant funding and accepts no advertising.

References:

1] Dr Bill Kirkup CBE, March 2015. The Report of the Morecambe Bay Investigation. pp184.

2] Broderick, C. April 2019. Listening to women and families about Maternity Care in Cwm Taf. pp6.

3] https://twitter.com/ShaunLintern/status/1196784902823391232/photo/1

4] Care Quality Commission, March 2019. Learning from deaths A review of the first year of NHS trusts implementing the national guidance. pp4.

5] Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Executive Summary. February 2013. pp13.

6] Public Inquiry into the Mid Staffordshire NHS Foundation Trust, Volume 1, Chapter 3 pp 245