|
What is the collective noun for maternity reviews?
A ‘slew’, a ‘library’, a ‘collection’? Perhaps a compost?
Baroness Amos is the latest to pile her efforts on the heap. She says ‘nothing prepared her for what she found’. Where has this woman been!
We do not need more hang-wringers, we need anvil-bashers, hammering out solutions.
A decade of inquiries, thousands of pages, the same recommendations cut-and-pasted.
Women are harmed, babies dead, families destroyed… Trust boards ‘accept the findings’ move on. Nothing changes. It's criminal.
D’ya know what… the usual excuses don’t wash… at least not for me. Not anymore.
Race is wheeled out as an explanation; ‘disparities,’ ‘institutional bias,’ but look around any maternity unit…
… a high percentage of the workforce is from ethnic minority backgrounds.
This indicates structural bias... assumptions and stereotypes fill the gaps. The higher the seniority, the less diverse the workforce often becomes and senior roles shape care pathways, culture and escalation behaviour., but...
... racism alone cannot explain poor care.
Something deeper is wrong. Something woven onto the fabric of maternity care.
Another favourite; ‘staff don’t care’.
Really?
Midwifery is not a profession you drift into. You don’t choose 12-hour shifts, traumatic births, the emotional labour of families in crisis and the risk of litigation…
... unless you care.
On paper we have more midwives per head of population than most comparable countries... but the figures mislead.
- Complex pregnancies,
- uneven distribution,
- part-time working
- high attrition mean...
... fewer available on the ground. Safety depends on midwives per shift and skill mix, not population ratios. The numbers look fine; women feel the shortages.
The system itself crushes good midwives.
Exhausts them, isolates them, blames them and replaces leadership with hierarchy and hope with fear.
-
When a unit is short-staffed, morale collapses.
-
When leaders churn every 18 months, culture collapses.
-
When concerns are ignored, safety collapses.
We have created a treadmill of failure and then we commission another review to diagnose the obvious.
Every review has said the same things;
- Short staffing.
- Poor teamwork; midwives, obstetricians and neonatologists.
- Weak leadership.
- A culture where people are afraid to escalate.
- Families dismissed or patronised.
- Training neglected.
- Lessons unlearned…
… every… single… review... blah, blah.
Nothing changes because the recommendations drop into the void between Westminster, DHSC, NHSE, Trust boards and the front line.
Nobody owns the solution.
The answers?
1. A single, national accountability line for maternity safety
One body. One person. One objective: stop babies dying unnecessarily.
Put the National Maternity & Neonatal Taskforce, on a statutory footing with inspection, intervention and enforcement powers. Forget the useless CQC. They're spectators who’ve watched quality across the NHS collapse.
2. Mandatory, minimum staffing ratios.
Published daily. We have the technology to do it. Midwives could tap-in when they arrive and the data could be on the Secretary of State’s laptop in real time.
Make the Secretary of State personally responsible for safe-staffing. He wants to run the NHS... so do it Wes.
Accountability changes everything
3. Protected, funded multidisciplinary training, ring-fenced like fire safety
Not optional, not cancelled when the rota collapses. Annual team training for every midwife, obstetrician, anaesthetist and neonatal nurse. Funded nationally, delivered locally, audited centrally. Incentivise nurses to become midwives... they'd bring a rich set of people experiences.
4. Boards held personally accountable for maternity outcomes
No more ‘we accept the recommendations’
malarkey. Make maternity outcomes a condition of reappointment for Chairs, NEDs and CEOs. If children die from preventable failings, out-they-go… leadership should change… not the narrative.
Accountability changes everything.
5. A national family liaison service
Standardised, trained, independent from Trusts. Families deserve honesty, not spin. Ask Donna Ockenden to set it up.
6. Stop leadership churn in troubled units
Three-year minimum postings for Heads of Midwifery and Clinical Directors in units rated ‘requires improvement’ or ‘inadequate.’
Accountability changes everything.
7. Routine cross-hospital birth case reviews
Neighbouring maternity units review each other’s cases as learning exercises, not investigations. Publish them quarterly.
Internal reviews are riddled with blind spots, defensive culture and group think.
Buddying-clusters of exchange senior midwives and obstetricians for routine and serious-case reviews each month. Create a national template and protected time. Fresh eyes, faster identification of risks and shared improvement across a region.
We must fix a system that is institutionally incapable of learning.
There will be 1,500 babies born in the NHS today.
-
It’s naive to think everything will go right for them all.
-
It is unbelievably stupid to think if something does go wrong, we can’t learn from it, make sure it doesn’t happen, tomorrow.
If we don’t act now, we are condemning the next generation of mothers and babies to the same cycle of failure and inquiry, and…
... after everything we already know, that would be unforgivable.
| 
