I’ll admit that I was a little puzzled when I first met Carl Hendrickson. He’d come to a discussion I held with families affected by poor care at Morecambe Bay in Cumbria, and I’d wondered why he had insisted on bringing his young son with him to my offices.
He sat down and calmly told me his story. He spoke about how he met and fell in love with his wife, and of the joy they felt together when she gave birth to their first child. And then he described the nightmarish series of events that led to him losing both his wife and a second child because of poor care.
Carl explained that he had brought his son because he wanted him to see with his own eyes that he had taken his concerns right to the top. He’s one of many incredible campaigners, including others like James Titcombe, Melissa Mead and Sue Morrish, who have chosen to relive their personal tragedies in the hope of making the NHS safer for us all.
Earlier this year, we heard why this work is so desperately needed. A global report by Unicef found the UK ranked 27th among high income countries on a key index of maternity safety – namely, how many babies die during the neonatal period of up to 28 days after birth. The study also estimated that four in five neonatal deaths around the world could be prevented.
From faster identification of sepsis and other infections, to better information about spotting potentially fatal complications during pregnancy, the NHS is working hard to improve its own record. Thousands of health professionals have been working together to improve clinical standards, resulting in a 15 per cent drop in the stillbirth rate since 2010.
But there’s a long road ahead if we want to catch up with the safest countries to give birth (currently Iceland and Japan) and that’s why last year I brought forward the challenge to the NHS of halving the rate of stillbirths, maternal and neonatal deaths and brain injuries occurring during or soon after birth from 2030 to 2025. If successful, this would save an additional 4,000 lives a year and make us one of the safest healthcare systems in the world.
So how will we do it?
One of the most important things we can do is to make sure that, when something does go wrong in the NHS, we understand why and we learn lessons from it. From April, around 1,000 families experiencing a stillbirth, neonatal or maternal death or severe brain injury during labour will be guaranteed a wholly independent investigation from experts in the newly established Healthcare Safety Investigation Branch. We are also going to look into allowing coroners to conduct inquests into stillbirths – at present, coroners can only investigate the deaths of babies who show signs of life after being born, not full-term babies who died during labour. We are exploring ways to make sure more parents get the chance of a full explanation.
The second important thing is that the NHS responds more openly and compassionately to families who have experienced child loss. At present, extraordinarily painful cases are being made worse because parents often experience a defensive and blocking response from the NHS when they raise concerns about care.
Many feel that their only recourse is to pursue their case through the courts, which means that the opportunities to learn and apply lessons quickly after an error are lost as a result of protracted legal processes.
We are therefore aiming to introduce a new “rapid resolution” scheme offering families of children who experience avoidable severe brain injury faster access to compensation and support without going through the courts.
The sad fact is that some baby deaths cannot be prevented, but what we can do is make sure the NHS gives grieving families the support they need to cope with such unbearable personal tragedy. And so thirdly, we are going to look at what more we could do specifically to support parents who have late miscarriages of up to 24 weeks.
In particular, I want to look at making sure these families have the right to certify and register their babies on official records – something that can mean the world to grieving parents – as well as making sure mothers get the same package of care, including bereavement support, as those experiencing a stillbirth later in pregnancy.
Above all, for a woman giving birth, the relationship with her midwife is absolutely crucial to making her feel safe at one of the most vulnerable moments in her life. That’s why last month I announced a plan to give all women care from the same midwives throughout their pregnancy journey and birth.
The statistics are clear – women who get to know their midwives personally are 19 per cent less likely to miscarry,
16 per cent less likely to lose their baby and 24 per cent less likely to have a premature baby. Some hospitals already follow a “continuity of care” model, but we want this to be the case throughout the NHS, and to do so we will be expanding midwifery training places by 25 per cent from next year, with plans to train 3,000 more over the next four years.
None of these measures, I realise, can help bring back a single baby who has died, but they will mean that the NHS responds to these unfathomable tragedies in a kinder, gentler and more thoughtful way, and learns the deep lessons that can prevent similar tragedies in the future.
And this, ultimately, is the best tribute we can possibly pay to Carl and many other bereaved families whose simple request is that the NHS listens and learns from the mistakes that it has made.
Jeremy Hunt is Secretary of State for Health and Social Care.
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