UK BBC News: Shrewsbury maternity scandal: Repeated failures led to deaths, 2022

Coverage of the scandal at Shrewsbury maternity hospital

https://www.bbc.co.uk/news/uk-england-shropshire-60925959

 

Ockenden report: the refusal of our healthcare service to take patient experience seriously

"Instead of seeing patient feedback as a foundation stone of high quality, evidence based care, healthcare providers too often see it as a threat. This is what James Jones observed when he described the interests of patients and relatives caught up in the Gosport scandal as being “subordinated to the reputation of the hospital and the professions involved.”4

It is what Julia Cumberlege meant when, in reporting on the thousands of women and babies injured by Primodos, Sodium Valproate, and pelvic mesh, she described “a culture of dismissive and arrogant attitudes that only serve to intimidate and confuse.”5

It is what Robert Francis exposed when, in the Mid Staffordshire inquiry report, he said that “for all the fine words printed and spoken about candour, and willingness to remedy wrongs, there lurks within the system an institutional instinct which, under pressure, will prefer concealment, formulaic responses, and avoidance of public criticism.”6

Time and again—and independently of one another—these reports come to the same conclusion: that an NHS which is meant to be both person centred and evidence based will not, when the chips are down, treat patient feedback as evidence.

So here we are again. Another large scale failure. Another “watershed” moment. Another series of apologies and promises to “learn from mistakes.”"

https://www.bmj.com/content/377/bmj.o875

 

The common factor to this kind of problem is almost always impunity. Whatever the context, impunity drives people towards bad behavior. Even good people.

How do people learn from mistakes if the mistakes don't affect them one bit? Spoiler: they don't. This is literally what learning is.

 

The other side of this is that there is always the media ready to pounce and a politician ready to be scandalised that their opponent has let something so awful happen. It makes it impossible to have a proper discussion of what is going wrong and fiz things so it doesn't happen again.

Think of the millennium bug - what a laugh when planes didn't fall out of the sky but people worked day and night sorting the problems but got no thanks for what they did.

Then the flu pandemic where they brought in vaccines and things so it was not the disaster it could have been but again it only brought criticism.

When infections like MRSA brought microbes to public notice after years of forgetting they existed (which allowed the "everything is psychological" brigade to thrive) it had to be someone's fault.

We live in a culture of blame (including blaming patients) and it is no help to anyone. There has to be an answer and we should be looking for it, openness is vital. If people have been corrupt or incompetent it needs called out but the beginning has to be a clearheaded examination of facts.

I don't see it happening though

 

Currently (half) listening to a radio phone-in (UK) discussing women’s experiences of maternity services following an inquiry into birth trauma.

Some horrendous experiences.

The one thing that stood out for me was that patients were not listened to - for example when describing their level of pain - they were often not believed.

 

I was working as a programmer in the late 90s when the palaver about Y2K was in full force. The stories told about it after the event suggest it was all over-blown hype and just a lot of nonsense. But in reality, lots and lots of people worked their socks off to fix the problems it caused before they actually happened. And when 1st January 2000 came along, if there were any really big problems they were often kept secret because they were embarrassing to companies. I know of one large UK company (and I'm not going to name names) that couldn't function properly for about 10 days once Y2K kicked in.

 

Poor maternity tolerated as normal, inquiry says

An inquiry into traumatic childbirths has called for an overhaul of the UK's maternity and postnatal care after finding poor care is "all-too-frequently tolerated as normal".

The Birth Trauma Inquiry heard harrowing evidence from more than 1,300 women - some said they were left in blood-soaked sheets while others said their children had suffered life-changing injuries due to medical negligence.

Women complained they were not listened to when they felt something was wrong, were mocked or shouted at and denied basic needs such as pain relief.

https://www.bbc.co.uk/news/articles/c4n1jv7xxpwo

 

I don’t how to express what I want to say here. This is cruel and tragic beyond words.

You can’t touch with words the experience of putting your life at risk for a pregnancy, only to have the people and institutions that are responsible for keeping you as safe as possible during such a perilous time as a pregnancy turn around and torture you. Putting your own and your unborn child’s life at higher risk, perhaps maiming, perhaps killing, one or both of you.

If through some chance you both should make it through such treatment without permanent physical damage, how will you trust?, Who will you trust? How do you ever seek care again? How do you allow anyone from this realm near your child again if they should sicken? How do you know whether or not ‘care’ in such a system is more likely to kill or cure them?
How do you make that call?


I think this report makes clear that from the very beginning of life, the medical profession may turn against you. While you attempt to bring forth life into this world the system may crush you, may snuff out life.

Now many people the majority of people, will claim to revere expectant mothers and their soon to be born babies. The reality of an experience in the healthcare system might suggest either people really aren’t being terribly honest about their actual feelings on these matters. Or that those making the medical and administrative and funding decisions, that determine the quality of care available, are differently minded.

It is entirely unsurprising that if our society and the sectors of our society to whom the task is specifically allocated and accepted by, find it simply too burdensome to have to properly care for those who, no matter how far we lean ideologically and non-ironically (all apologies to the originator of the concept) into bootstrap-ism, absolutely cannot take care of themselves while giving birth or being born, that every other person falling temporally and otherwise outside this specific category also cannot be assured that they will be met with kindness and care in moments of vulnerability and peril. Or that something entirely more horrifying isn’t in store for them at the hands of those charged with their care.

 

I'm trying to think of whom this is good for and I come up with nothing. It's certainly not tolerated by the mothers, that's for sure, so only one party is tolerating this: the people doing this and their work structure. And why are they? How is this good medicine? Who does this serve or help? It doesn't even save money. Usually it's money and you can think that, yeah, they're just cheapening out but added all up it doesn't even do that. It only sounds like power trips in a dysfunctional system that can't even guarantee the most basic minimum level of quality. Because it doesn't have to. Because failures just keep getting covered up, abusing medical secrecy to protect the system from accountability.

This is as basic health care as it gets, something that's been done for millennia. And they can't even get the most basic parts of this right?

Again and again it comes down to the aristocratic build-up of the whole system, the complete imbalance of power that gives patients no agency, even as medicine is building up the same concept of agency to deny basic health care elsewhere.

Health care hasn't reached its minimal viable product yet. It's still a mess, and this part is not improving. Almost everything else is, and despite this, the basics aren't improving.