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Worthy of the ‘global leader’ hype, or are we seeing the tip of the iceberg?

12 December 2019
Volume 28 · Issue 22


John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses some recent patient safety crises, litigation claims and a new patient safety publication from NHS Resolution

Unfortunately, it is never too long before a major patient safety crisis hits the NHS and we saw this recently with the Shrewsbury and Telford Hospital NHS Trust maternity scandal.

‘Hundreds of families whose babies died or were seriously injured at the Shrewsbury and Telford Hospital Trust do not even know their cases have been identified for investigation in the biggest maternity scandal to ever hit the NHS, The Independent can reveal today. Dozens of babies and three mothers died in the trust's maternity wards, where a “toxic culture” stretched back to 1979, according to an interim report leaked to The Independent this week.’

These events follow closely in the footsteps of the Morecambe Bay maternity scandal where tragic avoidable harm occurred to mothers and babies. The events at Morecambe Bay were unforgivable in an NHS that prides itself on good-quality care and an efficient, effective patient safety system.

‘Clinical competence was substandard, with deficient skills and knowledge; working relationships were extremely poor, particularly between different staff groups, such as obstetricians, paediatricians and midwives; there was a growing move amongst midwives to pursue normal childbirth ‘at any cost’; there were failures of risk assessment and care planning that resulted in inappropriate and unsafe care; and the response to adverse incidents was grossly deficient, with repeated failure to investigate properly and learn lessons.’

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