At an inquest last week, I represented the parents of a baby girl who died in 2015 at Watford General Hospital. The coroner agreed that on at least four occasions, staff on the maternity ward missed the opportunity to react urgently to pathological CTGs (readings of fetal heart beat) and to deliver the baby by C-section. Once she was born, further mistakes were made that delayed a vital blood transfusion. The coroner's conclusion was that a combination of fatal mistakes caused the baby's death.
It is an unpalatable truth that the UK's stillbirth rates are the highest in Western Europe. Now, a worrying investigation by the BBC has revealed that NHS maternity units in England recorded an average of more than 1,400 mistakes a week between 2013 and 2016.
The figures, obtained via a Freedom of Information request for the Victoria Derbyshire programme, found that figures from 81 NHS trusts, out of the 132 in England, stated that 305,019 adverse incidents, from missing records to the death of a mother or baby, were recorded during those four years. And figures from 39 trusts show 259 deaths of mothers or babies were recorded as avoidable or unexpected.
An inquest is agonising for grieving parents. It is very difficult to hear evidence about what happened and admissions that with appropriate treatment their baby would have been saved.
In this case, the hospital trust had already admitted liability before the inquest, partly because of a damning internal investigation that revealed a catalogue of errors and mistakes during the woman's 14-hour labour and a fundamental lack of communication and training, particularly involving the use of CTG monitoring.
During evidence, a spokesperson for the trust admitted, "We could have done things so much better". He also discussed the many changes that have been implemented following the review, including better training and leadership and the creation of new roles.
Although the whole experience was deeply distressing for the family, they were relieved to hear that the changes implemented by the trust will hopefully prevent other parents experiencing a similar tragedy. This is of small comfort, but perhaps at least a tiny glimmer of hope in the urgent need to improve the care provided to mothers and babies by our hospitals.
The Government has said it is committed to halving rates of stillbirths, neonatal deaths, maternal deaths and brain injuries in babies by 2030 and, as part of that commitment, launched an £8m maternity safety training scheme in October 2016.
This is welcome news, but, as the Royal College of Midwives points out time and again, safety is still being compromised by the pressure maternity services are under. Change and improvement can only be achieved with long-term investment and proper funding.
Responding to the BBC report, Cathy Warwick, chief executive of the college, said: "We need to reduce the number of mistakes to an absolute minimum. We can't deliver the safest possible care if we don't have enough midwives and doctors working here."
At Fieldfisher, we see too many families devastated by the loss of their baby. The maternity safety training scheme is, at least, a start, but there is a long way to go.
Find out more information about birth injuries.