“It is only when there is learning and change, that patient safety, which is in the interests of the patient and the NHS, will improve.” says Shoosmiths’ clinical negligence specialist partner, who represented several of the families in the long running NHS inquiry into failings at the trust.
The Ockenden Report, released this morning, reveals that at least 295 babies died or suffered brain damage because of avoidable poor care at the trust and nine mothers also died as a result of avoidable poor care. In total, 1,486 families were affected with 1,592 incidents.
The report has now identified no less than 60 actions for learning at the trust and 15 immediate actions which must be implemented by all NHS Trusts in England who provide maternity care.
Kashmir firstly references point 12 in the report, which studied 498 cases of stillbirth, and the finding that “1 in 4 had significant or major concerns in maternity care which if managed appropriately might or would have resulted in a different outcome”.
She said: “If the Trust had managed the birth appropriately, our client Kamaljit would not have suffered the tragic loss of her son shortly after his birth.
“She asked for a caesarean section on more than one occasion as she was worried about the safety of a vaginal delivery, but her requests were simply dismissed. We are concerned that this was because the trust had a policy of “normal births”.
Kashmir was also keen to highlight the stated failures in governance and leadership noted in the report, which said “trust leadership up to board level was in contestant churn and change”and “failed to foster a positive environment to support and encourage service improvement.”
The report found that “investigatory processes were not followed to a standard that would have been expected, Reviews were cursory and not involving MDT and did not identify the underlying systemic failings and significant areas of concern.”
She said: “Systemic failings will always compromise patient safety and in the case of maternity care, the consequences are the devastating deaths of mothers and babies.”
Point 15 of the report noted that along with staffing and training the Health Select Committee clearly articulated the need to learn from patient safety incidents. It endorsed findings that families must be involved in the investigative process and that lessons must be learned and implemented in a timely way to prevent further tragedies.
Kashmir said: “It is inevitable that mistakes will occur, but the failure to learn from those mistakes is such a missed opportunity. It is only when there is learning and change that patient safety, which is in the interests of the patient and the NHS, will improve.”
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