An expert on maternity care deaths lambasted hospitals for a culture of ‘defensiveness’ and a refusal to accept mistakes have been made when things go wrong.
Dr Bill Kirkup CBE, who led an inquiry into the deaths of 11 babies at Morecambe Bay hospitals, called for more ‘openness and candour’ instead of a tendency to underreport and play down incidents even when babies have died.
Her was speaking at the inquest into the death of Ida Lock who suffered a brain injury due to lack of oxygen at the Royal Lancaster Infirmary in Lancashire in November 2019.
A coroner in Preston has heard of a series of failings at the time of her birth including a delay in calling a crash team, midwives giving baby Ida ‘ineffective CPR’ and medics having to crawl under the bed in the cramped delivery room.
Ida’s mother Sarah Robison, then 38, had been in a birthing pool as she prepared for delivery and there were serious delays in evacuating her while her baby’s heartbeat had dropped significantly over the previous 15 minutes.
Ida was taken to the Royal Preston Hospital, a tertiary centre providing specialised treatment, but died six days later.
Dr Kirkup told the inquest: ‘A baby that is healthy at 37 weeks ought to be healthy and going home at 41 weeks.’
Highlighting one of the problems that cause under reporting of such incidents he said the fact that tertiary centres deal with seriously ill babies meant no-one was addressing the problem of how they ended up there.
He was also severely critical of the University Hospitals of Morecambe Bay Trust which runs the Lancaster Hospital where, he said, staff had been unwilling to accept responsibility for Ida’s death.
A report commissioned by the hospital itself had found little wrong in the care and treatment of the baby and staff had refused to accept a report from the Healthcare Safety Investigation Branch – now known as the Maternity and Newborn Safety Investigation.
The HSIB criticised procedures and highlighted failures at the hospital but staff continued to believe they had done nothing wrong.
Dr Kirkup said: ‘They accepted the recommendations but disagreed with the reasons behind them.
‘The HSIB report is the definitive report. It is not open to dispute rather like an air accident investigation is not.
‘That was deeply hurtful and unhelpful for the family.
‘The hospital’s own internal investigations were of poor quality, superficial and defensive of staff involved to the point of obscuring the significant learning that should have been drawn from what had happened.
‘While the desire to protects staff can be understood, it should never take precedence over either the trust’s duty to those harmed or its responsibility for understanding the causation and preventing recurrence.’
Dr Kirkup is the author of the Kirkup Report, an investigation into UHMBT set up by then health secretary Jeremy Hunt in 2015 after the deaths of 11 babies at the trust’s Furness hospital.
Asked by coroner Dr James Adeley how he felt that he was now being asked questions about the same hospital, he said: ‘It is deeply disappointing. There are echoes of the 2015 investigation in the poor quality and defensive response that is likely to reflect a deep seated culture within the organisation.’
Addressing the failure of hospitals to monitor failures properly, he added:’I am not in favour of punishing people for clinical errors. They are a fact but it is the denial of things going wrong that leads to families being denied the truth and everyone is denied the chance to learn from mistakes.
‘Someone once said that punishing staff when things go wrong is the biggest obstacle to patient safety and to deny some thing has gone wrong simply perpetuates a cover up.’
‘We are still seeing the same things happening that were happening 20 years ago. That is a very saddening fact’.