January 7, 2014

The need for proper investigations of poor NHS midwifery care

The healthcare Ombudsman, Dame Julie Mellor, was asked to review the deaths of three babies and a maternal death at Furness General Hospital in 2008, following complaints from the families affected as they were unhappy with the investigations provided by the Trust internally. The purpose of the report was also to look into how the failures complained of were managed by the hospital Trust and Strategic Health Authority; the Ombudsman reported significant concerns in this regard.


The report was involved in reviewing four specific incidences of poor NHS midwifery care, however the Trust involved has also had a high level of medical negligence claims brought against it, including cases involving cerebral palsy claims.

The primary conclusion of the report was that local midwives had failed to raise the alarm about poor standards of midwifery care. In one of the tragic cases investigated both a baby and his mother died, however the midwife involved did not take matters further. The report concluded that she “should have identified a number of failings in the midwifery care provided to Mrs M, who was a high-risk mother because she had diabetes and was having her labour induced.” It went on to state that her baby’s heart “should have been monitored at regular intervals using continuous fetal heart monitoring from the moment Mrs M arrived in the delivery suite”, but this was not done.

This is just one example of the investigatory failures note and the report makes for sad reading, not only in terms of the original negligent medical care provided, but also the manner in which the issues were investigated thereafter.


Dame Mellor commented that there were “real weaknesses” in the local supervision arrangement for midwifery care. She highlighted the difficulties in midwives’ dual role of supervising and critiquing their colleagues, whilst at the same time working with staff as team members, responsible for their career support and development. This apparent conflict of interest has resulted in calls for the two roles to be separated.

The families of those affected noted the need for change and the “substantial recommendations for changing the system of midwifery supervision in the UK.” They went on to complain about the lengths they had to go to in order to achieve the Ombudsman’s review, involving the threat of judicial review.

It is indeed shameful that the NHS complaints and review system created barriers to bereaved families seeking the explanation they clearly deserved as to why NHS systems failed in their cases. It is hoped that a new ‘duty of candour’ on NHS staff will go to avoiding such additional stress to families and deal with medical negligence in an open and transparent way.

As medical negligence solicitors we continuously hear complaints from our clients that medical staff failed to listen or take seriously their concerns, never mind assist with a complaints process. The agony of the families affected by the poor care at this Trust was only prolonged and enhanced by the failure to properly investigate the deaths. Addressing the issues early can only be beneficial for both medical staff and those patients affected.

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