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Feminism: Sex and gender discussions

Another investigation into a maternity unit

11 replies

RedToothBrush · 24/01/2020 08:11

This time East Kent.

www.independent.co.uk/news/health/east-kent-hospitals-baby-deaths-maternity-nhs-criminal-investigation-a9298111.html
East Kent hospitals: Criminal investigation into baby deaths at maternity unit
Warning in 2016 that lives were at risk because consultants were not showing up for weekend and evening shifts

The Independent has learned of dozens of deaths at east Kent hospitals with more than 130 babies suffering brain damage as a result of being starved of oxygen during their birth over a four-year period.

And

An expert review of the maternity services by the Royal College of Obstetricians and Gynaecologists (RCOG) carried out in 2015 had warned of many of the issues that played a part in Harry’s death, including the reluctance of a group of senior doctors to attend during evening and weekend shifts leaving ill-prepared junior doctors and midwives to care for complicated births.

The experts explicitly warned bosses at the trust that if action was not taken it would mean consultants not committed to teaching and supervision would “be on-call with a locum middle-grade doctor, potentially of unknown competence, which could impact on the safety of care in the maternity unit”.

An audit by the trust in 2016 revealed only a 68 per cent attendance rate for consultants at the Margate hospital.

OP posts:
Uncompromisingwoman · 24/01/2020 08:28

This is a persistent issue country wide isn't it? Poor quality maternity services, toxic cultures and women and babies suffering the consequences.

sycamore54321 · 24/01/2020 08:38

That is heartbreaking. Those poor women, those poor babies, their poor families.

I am immensely concerned about the state of pregnancy and particularly childbirth care in the UK. And much of it is being driven to ever-lower, more unsafe standards by various constituencies of women. They obviously don’t directly push for lower standards but that’s what they get. The fetishisation of “normal birth” (horrible term), exclusive breastfeeding, a race to the bottom in the level of medical care deemed desirable at what is one of the most dangerous times of healthy women’s lives and the single most dangerous moment for babies. Consultant care is seen as something to be resisted at all costs, midwife led units better, a home birth with minisculely-equipped midwives seen as the ideal. Safe effective pain relief like epidurals is demonized and seen as failure, instead women in agonizing pain are told water should be enough. And instead of expecting trained skilled doctors and nurses, women are expected to settle for narrowly-trained direct entry midwives who are pushed into a “birth is natural, natural is good” ideology and who don’t have the depth of experience to recognize complications.

It’s a scandal. And it’s one largely perpetuated by women against their own best interests.

I appreciate in the specific case mentioned above, the focus is on doctors attendance. However my comments are on the more general downgrading of healthcare expectations for women in pregnancy and birth. It’s horrifying.

Kazzyhoward · 24/01/2020 08:53

including the reluctance of a group of senior doctors to attend during evening and weekend shifts leaving ill-prepared junior doctors and midwives to care for complicated births.

It's not just maternity.

Urology consultant Peter Duffy's whistle blowing book re Lancaster Infirmary contained the same claims about consultant/senior level urologists - i.e. some of them would "ignore" obvious signs that an operation was required, sometimes resulting in death or life changing complications. Not to mention, a consultant being called overnight or weekend by the ward sister to deal with an emergency, and simply refusing to attend or coming out the next day.

Mayomaynot · 24/01/2020 10:18

It really is scandalous. If the senior staff are needed, as they clearly are, then they should be there.

BadgertheBodger · 24/01/2020 10:36

I think a lot of trusts are mere millimetres away from a serious incident about 99% of the time. Communication is poor, many consultants seem to feel they have almost god-like status and behave in such a way. Nobody feels able to speak up about conditions or issues, even if they did nothing gets done about it. Layers upon layers of management doing fuck all managing.

I am absolutely appalled by yet another maternity scandal. Do they never learn from them? I was petrified of giving birth as we were living in Cumbria and my choice of hospitals were Barrow or Lancaster. Barrow has been beset with a similar scandal and I genuinely think we’d have been down the motorway to Preston with me in labour if Lancaster hadn’t had room. I had a dreadfully traumatic birth and DS nearly died but thankfully the care was excellent. I am so, so sorry for those mums and babies who have been damaged by shit “care” when they should have been helped. What an absolute disgrace.

FallingIguanas · 24/01/2020 11:56

Sycamore's post has struck a cord with me. As a midwife, increasingly I see decisions made in maternity care are driven by budgets rather than aligned at their core with women's best interests. I am considering leaving the profession because of this and the ever present fear that because of decisions made by management (staffing, downgrading of units) a woman/baby in my care may come to harm, despite my competence, ability to risk assess appropriately and "respond to complications" (yes, I am DE trained). I hope to be able write further (and consider campaigning) on this in time when I have reflected on my feelings surrounding this.

RedToothBrush · 24/01/2020 12:11

Some figures for context, because if the figures the Independent have suggested are right, its utterly appalling. How on earth did 130 incidents over 4 years go on for so long? Thats over 30 a year at the same trust.

The figures for Telford which are public suggest 51 babies brain were damaged due to oxygen deprivation between 1979 and 2017 are now being investigated. And in 2017 it was reported in The Telegraph that there had been 232 claims against the NHS in 2016-2017 for brain damage in maternity. The previous year it had been 188 cases.

The New Scientist reported the following in 2017 (the same year Harry died):
www.newscientist.com/article/2138065-babies-are-dying-during-childbirth-in-the-uk-due-to-poor-care/

Three-quarters of the babies who die or are brain damaged during childbirth in the UK might have been saved by better medical care, an inquiry has concluded.

And

Called Each Baby Counts, the report is a result of the Royal College of Obstetricians and Gynaecologists investigating 1136 cases of babies born in the UK in 2015 who either suffered brain damage during birth, or died during delivery or in the next week.

There was also this comment:
Maureen Treadwell from the Birth Trauma Association charity says the report looked at the right cases, but should have tried to identify which hospitals have higher rates of poor care.

The 'Each Baby Counts' report looks like it was the one in the report in the OP.

So we have all these targets for maternity, but it doesn't seem like the number of incidents where babies were deprieved of oxygen and it later emerged they were brain damaged are being monitored routinely.

Its now 2020 and its only now that the extent of the problem at East Kent seems to be coming out. There was an awareness of it as it was put in special measures but even then if the Independant's reporting is even half accurate you have to ask very serious questions. It suggests a complete systematic failure at not just an institutional level but at a national level to pick up on what was going on.

This is despite the fact that injuries caused by brain damage at birth make up a huge amount of NHS claims.

The latest Annual Report & Accounts by NHS Resolution, published this month, shows that maternity claims are still costing 48% of the total value of claims across all NHS disciplines, despite only making up 10% of the total number of claims. This percentage is a 2% drop from last year’s record high of 50%; however, it still remains the largest contributor by far of the total £4,513.2 million. The second highest contributor after maternity being 17%, which belongs to aggregated specialities labelled as “other”.

Most of the cost of maternity claims come from cerebral palsy/brain damage claims. The number of maternity cerebral palsy/brain damage claims has gone down by almost 10% from the previous year, dropping by 20 claims to 211; however, this was after a big increase of 42 claims (over 20%) in 2016/17 from 2015/16. The mean average number of claims from the year 2004/2005 to 2017/18 has been almost 219, and so it’s encouraging to see that the last financial year has been below the average.

To put it another way, NHS 'Health Tourism' which is apparently being cracked down on, costs us £1.8billion per year.

Yet there seems to be little to no effort to tackle the enourmous cost of maternity negligence by dealing with the issues that lead to incidents and there isn't a huge political drive to even acknowledge the problem properly.

Why?

There are saving to be made here, but more importantly, it would mean the lives of many were not destroyed in the process. Win Win.

UPDATE on the case in the OP

The final ruling in Harry's case looks to have just come out:
www.bbc.co.uk/news/uk-england-kent-51228194

The judge has ruled he died because of 'neglect'.

Coroner Christopher Sutton-Mattocks was told Harry was born not crying, pale, and with no movement in an operating room "full of panicking people".

Giving a narrative conclusion, he found Harry's death was "contributed to by neglect".

and

Mr Sutton-Mattocks criticised the hospital trust for initially saying Harry's death was "expected", which meant the coroner was not informed of Harry's death.

It was only because of the persistence of the family that an inquest was ordered, the coroner said.

and

Explaining his conclusion, Mr Sutton-Mattocks said he considered the divergences of unlawful killing or neglect.

"I do not conclude the failures were so large and so atrocious as to fall within the definition of unlawful killing."

I find the whole thing an utter scandal, that no one cares about because of an 'oh women and babies die and get injured at birth and thats just normal' attitude. There's no easy target to blame here. Just people in positions of power making budgetary decisions...

OP posts:
ThinEndoftheWedge · 24/01/2020 12:12

67 maternal death per year in 21st century UK.

Not acceptable

Nearly 3000 still births per year in 21st century Uk - 60% of which deemed preventable by The Lancet

Not acceptable

Infant mortality (number of babies who died up to day 28) rate now increased to 4/1000 in 21st century UK. No government target to reduce this.

Not bloody acceptable

RedToothBrush · 24/01/2020 12:33

Sounds like this is all clear as day

www.telegraph.co.uk/news/2020/01/23/nhs-trust-centre-maternity-scandal-has-highest-death-rates/
NHS trust at centre of maternity scandal has highest death rates

The NHS trust facing questions over seven preventable baby deaths has recorded the worst mortality rate for units of its type, official figures show.

East Kent NHS foundation trust has apologised and admitted it has "not always provided the right standard of care" in its maternity services, after significant concerns were reported.

A national audit of mortality rates shows that the trust has the highest perinatal mortality rate - the total of still births and baby deaths within 28 days of birth - of all units with comparable services.

and

The BBC has reported seven preventable baby deaths at the trust in recent years, and highlighted a damning review of the unit by the Royal College of Obstetricians and Gynaecologists.

and

A national audit called the Confidential Enquiry into Maternal Deaths in the UK shows that in 2017, the last year for which figures are available, its perinatal death rates were the highest in the country of trusts offering comparable maternity services.

The trust was placed into special measures in 2014 following an inspection by the Care Quality Commission which rated its care, including maternity services, as inadequate.

Remember it was REMOVED from special measures in early 2017.

WHY????

The Telegraph article measures a BBC investigation which has found 7 preventable deaths.

www.bbc.co.uk/news/health-51193332
Here is the BBC article detailing those.

It mentions
Archie Powell - 2019
Tallulah-Rai Edwards - 2019
Hallie-Rae Leek - 2017
Archie Batten - 2019 (inquest still pending)

All AFTER the hospital was taken out of special measures.

Some pretty big questions to be answered here.

OP posts:
SHAR0N · 24/01/2020 12:44

Lay Summary of report into maternal deaths
“ Saving Lives, Improving Mothers’ Care 2019”.

www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202019%20-%20Lay%20Summary%20v1.0.pdf

AmyFl · 28/01/2020 23:01

This reply has been deleted

Message withdrawn at poster's request.

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