Lessons must be learned from the ‘Each Baby Counts’ inquiry says leading Clinical Negligence lawyer, Marcus Weatherby
There are too many poor quality investigations into babies who die or are severely brain damaged during labour, a review says.
The inquiry, Each Baby Counts, has been set up to ensure lessons are learned when something goes wrong. The aim is by 2020 to halve the number of babies who die or are left severely disabled.
The Royal College of Obstetricians and Gynaecologists has published its preliminary report into how problems during labour are investigated. For an already beleaguered service it does not make happy reading.
– 27% of investigations were of poor quality.
-Almost 75% simply failed to include parents in any meaningful way.
In large organisation such as the NHS the ability to improve practices when mistakes are made should be fundamental. Yet there is widespread agreement that the NHS lacks the will or the ability to learn lessons from these tragic events.
At Pattinson and Brewer we see this in people who turn to us for help – more often than not in a system which has not been open about what went wrong. Sadly often the true facts come to light only through a Coroners enquiry or litigation.
Louise Silverton, director for midwifery at the Royal College of Midwives, admits that her members “are often working in systems that do not support best practice, and the safest and highest quality care as well as they should.”
The preliminary report of Every Baby counts coincides with the appointment of Keith Conradi’s as head of the new Healthcare Safety Investigation Branch which is intended to make the NHS safer. Mr Conradi was formerly UK’s chief inspector of air accidents .The new healthcare investigation body (HSIB) will begin work soon, with an initial budget of £3.5m.
It is to be hoped that the HSIB might usher in a culture of learning from mistakes within the NHS. There is an old saying that ‘Stupidity is doing the same thing over and over and expecting a different result. Ignorance is not caring’