'A culture of cover-up': the NHS maternity crisis exposed

The NHS is facing one of its deepest crises - a string of maternity scandals, from Shrewsbury to Nottingham, Oxford to Leeds. Hundreds of babies have died or been left severely injured in hospitals meant to keep them safe.

So why does this keep happening? Is it about funding, training, or a system that protects itself instead of patients?On this episode of The Fourcast, Krishnan Guru Murthy is joined by Jeremy Hunt MP, who was the Health Secretary between 2012 and 2018; Channel 4 News Health and Social Care Editor Victoria Macdonald who recently reported on a maternity scandal at Oxford University Hospitals. The Trust there has apologised to families and said it was committed to learning from mistakes; and Kayleigh Griffiths, whose daughter Pippa died in 2016 due to failings in care by the Shrewsbury and Telford Hospital NHS Trust. 

Her investigation alongside another bereaved mother Rhiannon Davies into failings at the Trust led to Jeremy Hunt commissioning the Ockenden Review into improving maternity services across the country.  

Griffiths has also been critical of the health watchdog - the Care Quality Commission saying its oversight of maternity services was 'not fit for purpose.' 

The CQC said her complaints were being taken seriously and it was engaging with families directly.

Episode Transcript

(00:00):
The NHS is very dysfunctional. People are just terrified that
if they're honest about what went wrong, they're going to get
scapegoated and we end up, I'm afraid, with a culture of cover.
Up We're not just looking at a cover up culture, we're looking
at a blaming culture. We were blamed as families for
the deaths of our babies becausethey couldn't accept that
accountability. Stories that we keep hearing

(00:22):
time and again. Babies who have unnecessarily
died, been harmed, families leftbereft.
Now, I'm sure there have been some improvements, but because I
am still doing these heartbreaking stories, you know,
not enough is changing. Hello and welcome to the
forecast. The NHS is facing one of its

(00:43):
deepest crises, a string of maternity scandals.
From Shrewsbury to Nottingham, Oxford to Leeds, hundreds of
babies have died or been left severely injured in hospitals
meant to keep them safe. So why does this keep happening?
Is it about funding, training ora system that protects itself
instead of patients? To discuss all of this, I'm

(01:03):
joined by the former health secretary Jeremy Hunt, who
commissioned one of the first major maternity inquiries, a
health and social care editor, Victoria McDonald, who's been
investigating these scandals foryears, and Kayleigh Griffiths, a
campaigner who lost her daughterin one of the NHS's worst
maternity failures. Thank you all very much for
joining us, Victoria. First of all, you've done a

(01:25):
series of stories in the last few days.
Why are we here again? Well, we've been looking with
the New Statesman at Oxford University Hospitals Trust,
maternity and neonatal units, and it's the same story again of
babies who have unnecessarily died, been harmed, mothers
harmed, families left bereft andagainst a background of

(01:46):
defensiveness in the trust of parents not being listened to,
of a lack of duty, of candor, The same thing that we've heard
over and over again. One mother who had twins who
were born at 24 weeks, one of the twins was taken away, wasn't
resuscitated, was then brought back to the mother saying, oh,
the morgue wouldn't be able to take this baby because it's

(02:07):
still breathing. And she was left with this baby
having to keep it warm on the radiator until it died.
Those sort of stories that we keep hearing time and again.
Kayleigh I mean, after such a long and difficult public battle
for you, how did hearing about another series of disasters make

(02:28):
you feel? I mean, for me, it's just
heartbreaking having to listen to the same, the same thing and
the same stories over and over again.
And I mean, to, to take a baby back to its mother that was
still breathing. I mean, I just can't even
comprehend that, that somebody would do that.
But I mean, fundamentally, we know what the issues are.

(02:49):
We've, we've heard time and timeagain that, you know, we know
the issues, but we're just coming up with a barrier of
actually implementing any of these recommendations.
And it's we, we just, you know, we need seriously to get to the
bottom of what, what, what the barriers are and get, get these
recommendations implemented now.Jeremy, why is it so hard to get

(03:09):
these things changed? It's hard partly because the NHS
is very dysfunctional. So everyone has this idea that
it's a a centralised well run machine where someone at the
Department of Health or NHS England can say do this and
tomorrow every maternity unit inthe country does it.

(03:32):
Unfortunately it doesn't work like that because you know,
these maternity units are very busy places and the doctors, the
midwives, the nurses have got a lot on their plate.
And the thing which is most disappointing is that you can
have a mistake say in Blackpool and a coroner can say we need to

(03:52):
change the system so that this doesn't happen again.
And then exactly the same thing will happen in Oxford or
Cornwall, you know, a few monthslater.
And I think the thing that worries me the most, Krish, in a
situation we're in is that we'vegot into this mentality of
uncovering another scandal at yet another hospital.

(04:13):
And I think we need to be honest, we've got these problems
throughout the NHS. Let's let's stop saying this is
a particular issue at Shrewsburyor Morecambe Bay or or Leeds or
Oxford. You know, throughout the NHS we
have got profound problems in the way we deliver maternity
services and we really do need change.

(04:34):
Right. But to to what extent is the
defensiveness of the NHS the fact that people's jobs are on
the line and they will inevitably try and fight for
their own position at the core of the problem?
Well, I think that is the biggest problem that we have.
And I think, look, I don't want to be defensive because these

(04:55):
stories are heartbreaking. It's heartbreaking for me
because I, you know, when I was health secretary, this was
probably my absolute top priority.
But I think it is worth saying that since the original
Morecambe Bay statement that I gave to Parliament in 2015 that
the Kirkut report, baby deaths have fallen by about 20% across
the NHS and the number of children born at term with

(05:17):
severe disabilities is down by nearly 1/3.
So there has been some progress made, but it's not enough.
And I think at the heart of it is a really big problem that if
you are a, an obstetrician or a midwife and you make a mistake
and there's a tragedy as a result of it.

(05:38):
You worry that if you're open and transparent about what
happened, you, you, you hold your hand up.
You say, I think I may have madea mistake, I should have done
this, but instead I did that. You worry that you're going to
get fired. And we have not learnt in the
NHS to do what they do in the airline industry, which is
distinguished between gross negligence, you know, a pilot

(06:00):
turning up to fly a plane when they're drunk, for example,
which there is, you know, there can be no forgiveness.
They should never fly again. And the kind of ordinary human
errors that everyone can make. And because we don't do that,
people are just terrified that if they're honest about what
went wrong, they're going to getscapegoated and we end up, I'm
afraid, with a culture of cover up.

(06:23):
I mean, Victoria, I mean, in your stories this week, you, you
didn't just uncover defensiveness, you uncovered
aggression. Yes, well, that is true.
I mean, there were some extraordinary legal letters sent
and and which we can't go into too much, but the but I, I agree
to a certain extent with Jeremy Hunt on the the sort of culture

(06:45):
and they being too scared to putyour head above the parapet.
But I think it goes further thanthat.
I think it is there is so much more about the way people are
trained, the way, the way that the NHS has been starved of
money. And, you know, let's not forget
that that Mister Hunt was there during the, the time of
austerity When, when, you know, spending was not keeping up with

(07:08):
inflation. And I think it has progressed
from there. There's also this idea of the,
the NHS always being, you know, turned upside down and
reorganized and, and it has justleft people exhausted and not
wanting to do the right thing, which has put their hands up.
There is also a litigious element to this.

(07:28):
So we had one story where this this baby was the the consultant
left the room during the caesarean section, left it to a
more junior member of staff, came back in, it was all going
wrong, yanked the baby out with some faucets and that baby is
now quadriplegic. Now that surgeon did say to the

(07:50):
the parents, I'm really sorry. Took 12 years for the trust to
admit 100% of liability. That story spoke to me volumes
of what is going wrong on the maternity units.
Kayleigh, to what extent do you think this combination of
defensiveness, legality and resourcing is at the centre of

(08:14):
this? And I think massively at the
centre of this. I mean, when you look at we're
not, we're not just looking at acover up culture, we're looking
at a blaming culture that, that,that not necessarily within the
NHS, but we were blamed as families for the deaths of our
babies because they couldn't accept that accountability.

(08:36):
And when we look at accountability, has anybody
actually been held accountable for the continuous failures that
have been uncovered within maternity services?
Because we were promised accountability when Ockendon was
published. But actually we've, we've had
nothing to date. And I think, I think denial

(08:57):
because as, as Derek Richard said, the grandfather of, of
Harry, denial is the biggest thief of learning.
And by blaming the parents, not listening to the parents, not
listening to whistleblowers, allthat we ever wanted was, was
learning from, from Pippa's death.
And, and actually it, it was just so counteractive.

(09:19):
We've never, you know, I've never as as a bereaved parent
wanted to blame somebody. All I ever wanted was to
actually work with that hospital, to put systems into
place that made sure that that never happened again.
And with this culture that's, that's, you know, continuing, we
just can't, we can't get past that.

(09:39):
We can never work together currently by without addressing
those problems. Jeremy, what, what, what about
resourcing? I mean, when, when you're
changing the way a system runs, you know, are you able to
adequately think about culture and the way people think and
approach accountability as well?Well, I think, you know,

(10:01):
accountability and resourcing are two different things.
I mean, on the resourcing side, when I became health secretary,
the first thing I dealt with wasMid Staffs and everyone said to
me, I'm sure you probably did ina Channel 4 interview.
You know, the, the issue here isshort staffing.
We don't have enough, you know, nurses in the wards.
And so that's why I made every hospital publish the number of

(10:23):
nurses they had on every shift in every ward.
And we saw a big increase in staffing.
And so, I mean, over the last decade in maternity, for
example, midwives is up 11%, nurses, maternity nurses up a
third, obstetricians up nearly 2/3.
So it's been quite a big increase.

(10:44):
But unfortunately, we haven't seen a commensurate fall in the
number of tragedies like Pippa'stragedy.
And I think that this defensiveness is the thing that
worries me the most. So many parents that I speak to
say exactly the same thing. They're not looking to blame
anyone, but they also say that very often when something goes

(11:06):
wrong, literally the only personwho's on their side is a lawyer
and they therefore end up in these very protracted legal
disputes which take 57, as Victoria said, 12 years.
And during any kind of litigation, hospital doctors,
sorry, hospital lawyers, tell doctors not to say anything at

(11:28):
all or say the very bare minimumnecessary.
And, you know, I really think weneed to look at whether we
should have no fault compensation where compensation
is automatic when someone has been wronged by the NHS.
It's the system they have in NewZealand.
Overall, it doesn't cost, it costs actually less than the the

(11:49):
bill that we pay here for clinical negligence.
And I'll just give you one example because I think it boils
down to, you know, Derek Richford's point about learning
in Japan, they introduced no fault compensation for babies
born with severe cerebral palsy.And they did it about 15 years

(12:09):
ago. And since then, they saw a fall
in about 1/3 of the babies born with severe CP.
And the reason was because instead of getting involved in
very complex, expensive court cases, parents got automatic
compensation. And hospitals can concentrate on
learning from what went wrong. And it's that learning culture.

(12:32):
I feel that, you know, that the midwives and nurses and doctors
involved, when these things go wrong, they actually want
nothing more than to really learn from it and to make sure
the same mistake is not repeated.
But the structures we put in place make that virtually
impossible. I think one of the things that
hasn't been discussed actually here is training and it's not

(12:55):
just the way there was a change in in the way midwives were
changed. So they're trained, they're now
do three years of training. Before they used to have to be a
nurse and then go on to do specialist.
And I think there is an issue with that.
I was talking to an obstetricianthe other day who said, look,
the fact is that birth birthing has become more problematic

(13:18):
these days because women are older, they have more complex
conditions. You know, it's, it's always been
a difficult, you know, there have always been problems, but
it's getting harder and harder and the training is not
necessarily keeping up with that.
There is also a terrible hierarchical issue on the wards.

(13:39):
So what you will hear time and again is a midwife or a nurse
will want to escalate a problem and the doctor isn't hearing it,
or they're not there, you know, they're not in the room, or some
junior member of staff just won't want to say anything and
they sit on the problem. All of that, I suppose, comes
back to the culture, but it doescome back to the way training

(14:01):
needs to change. I mean, I'm speaking as somebody
who had a baby at 47. I mean, I fall into that cohort
of, you know, problematic older women giving birth.
But you can see this that the General Medical Council did try
at some stage, and I'm not sure if they're still doing it, to
get obstetricians and gynaecologists and nurses and

(14:22):
midwives to do some training together so that they could try
and deal with this hierarchical issue that that puts up such a
barrier on the ward when something's going wrong.
Jeremy. I agree with that and I think
that one of the biggest issues in training is on midwife
training where there is still a culture of so-called normal

(14:47):
births of trying to avoid getting a doctor involved in a
birth. And there was a big Sunday Times
investigation into this just this weekend.
And the issue is that sometimes it's taking too long for people
to get referred to a doctor where maybe AC section is the
safest thing for a baby in a particularly complex situation.

(15:08):
And the training colleges all have been saying for some time
they don't do this anymore. But the truth is that this still
does exist. And I do think that you're
absolutely right, Victoria. Teamwork and a culture that in
the end the only thing that matters is safety of mother and
child. That is the the most important

(15:31):
thing. Of course a woman must make the
final decision as to how a childis going to be born, but no
woman in practice would ever want to do anything but the
safest route. And sometimes they aren't given
that information. Kaylee, do you have a sense of
what needs to be done to drive that cultural change amongst
staff? You know, is it, is it just, is

(15:51):
it a matter of training or is itsomething beyond that?
I would say it's, it's training,it's, it comes down to funding.
You know, we're seeing the NHS being significantly stripped
now. That's why I work in, in the NHS
from a different type of trust, not an acute trust.
And we're seeing cuts that are coming down the line and it's

(16:13):
constant. And what we're seeing across the
board is, is burnout. We're seeing people that are
afraid to speak up, that, you know, whistleblowers are afraid
to speak out. It's, it's systemic, it's it's
culture, it's funding, it's improper regulation, it's
improper oversight that it's, it's huge.

(16:36):
Jeremy, can we, can we just focus on the, on the funding for
a second because both Victoria and Katie have raised it.
I mean, in your previous answer you seem to be sort of
suggesting it wasn't really about resourcing, Is that what
you're saying? Well, look, I don't want to
pretend that the NHS hasn't had a very difficult period.
I mean, what the the budget for the NHS in the 2010, I think it

(16:58):
was frozen in real terms. It wasn't cut.
But you know, there's been a lotof pressure in the NHS.
When I became health secretary about halfway through the
austerity period, I felt it needed more funding and I
secured a big increase in 2017 and it got a further increase in
the pandemic. I mean, you know, the facts are

(17:20):
that out of all the advanced economies, we, we're about the
fifth highest in terms of the proportion of our GDP we put
into health. So I, I think, you know, funding
has been an issue, but I also think it's about culture and I
think it's about structures and it's about training.
It's about all the, all these things that we say.

(17:41):
I think in terms of the actual question of the, the most
visible aspect of funding which is the number of staff that you
have. The the bit that is puzzling to
me is that you know, we've had about I talked about an 11%
increase in midwives. We've actually had about 11%
decrease in births because of a falling birth rate.

(18:03):
So, you know, it may well be that there are some return to
units that are short staffed, but I don't think that's the
only issue. And I think we have to look at
why it is that when there's a problem, it seems to be so
difficult to get people to speakopenly about it.
And, you know, I, I introduced something called duty of candor,

(18:26):
which basically meant that it was against the law for
hospitals to be anything other than truthful to families like
Hayley's family. When there's a tragedy or when
there's any kind of patient safety incident, and I think
it's had some success, but it hasn't worked in the way that
I'd hoped. I was hoping there'll be a much

(18:47):
more profound openness happeningin the system than we've seen.
So I think there are some deep seated cultural issues that we
need to look at as well. Can I just also ask you about
the regulation? Is the CQC fit for purpose?
It went really badly wrong afterthe pandemic, so I basically set
up the CQC in its current formatand it's the way I set it up was

(19:10):
that you should have experts looking at hospitals.
So a maternity unit is not goingto be investigated by a sort of
25 year old student on their first job.
It would be investigated by someone who was themselves a
trained midwife or trained obstetrician who knew what they
were looking for. And I think that is the right

(19:31):
way of doing it. In the pandemic, they after the
pandemic, they changed that system to generalist in struct,
in inspections. And that is now thankfully being
changed back. So I think the CQC is being put
back on its feet. But yes, it's had some very,
very big problems in recent years.
Victoria. Well, I mean, Kayleigh knows

(19:51):
better than I do. Perhaps you you can explain what
you and Rhiannon Davis, who's baby Kate died at Shrewsbury in
Telford. I mean actually did look at the
CQC and and found enormous problems with the way that they
were investigating. I mean, probably better for
Kayleigh to explain this. Yeah.
So Rhiannon and I undertook a piece of work.
We looked at all the focused CQCinspections that were undertaken

(20:15):
into maternity. So we, we, we read through all
of them. We found inconsistencies.
What we found was that previously, so trusts that were
failing in maternity were rated as good.
Once concerns were then raised by families, they were rated as

(20:37):
inadequate and failures then were were were spotted.
But to date I'm still seeing inconsistencies in the way that
they report. I don't think, I don't think
what what Jeremy said there about the sort of levels of
staff that you've got undertaking the inspections

(20:59):
currently. So they're, they're quite
inspectors are paid quite a low salary.
So I don't think you would expect that it attracts that
experience that that Jeremy would be expecting and they've,
you know, that then they're not able to pick it out where a
trust is failing and. And do you think patient groups

(21:21):
are taken seriously and and do you have a blueprint for how you
would change things, how you would make things better?
Yes. So we, we've, we've got, we've
got ideas. Those are family voices.
What I would like to see would be those services and the
families coming together to create the, the change in the

(21:42):
way forward. I don't.
I don't think it can be done in isolation.
I've seen like shoots, green shoots of high, high services
are working together with families, but there's still a
very, very long way to go. Jeremy, I mean, I don't know
whether you do you speak to WestStreeting about these sorts of
things. I mean, is there, is there
cooperation? Is is is your experience passed

(22:02):
on and shared? Yeah, I've had, I've had a lot
of discussions with Wes. I think he is very committed to
this. We had a, a debate in Parliament
for Baby Loss Awareness Week andyou know, unusually as Secretary
of State he came and sat throughthe whole debate.
He could have sent one of his junior ministers and he didn't.

(22:23):
And I think he recognises that. You know, what people like
Kaylee want is action. You know, we've had so many
reports now. I commissioned quite a lot of
them myself actually. And you know, in a way, rather
than more recommendations, for example, Donna Ockenden in her
reporting to Shrewsbury in Telford had a list of immediate

(22:43):
and essential actions. And we just need to get on and
implement those immediate and essential actions.
They are immediate and they are essential and we just need to
get on with them. Or if the government doesn't
want to do them, they need to say why they don't.
So I hope that this, you know, new review that Valerie Amos is
doing is going to report quicklyand we can just crack on with

(23:03):
doing the things that we all know need to happen.
But I do hope that as part of that, we look really hard at
culture change and we ask the difficult question as to what it
would take for doctors, nurses, midwives to be open in the way
that families want them to be open.
Because that seems to me, you know, even if the answer we get

(23:25):
is uncomfortable, we should findout what it is that is stopping
that openness. Because I think that is the
heart of why families feel time after time that they're not
being told the truth and that, you know, instance have been
covered up. When you look back, I mean, are
there things you, you know, you wish you'd done?
I mean, or have they brought youback now and said, look, what
should we do that politicians maybe don't turn to first?

(23:49):
Do you have recommendations? Well, the thing that I would
really like to do is is end thislitigation culture because I
feel that it is just a big barrier to, if you look at
Sweden, if we have the same maternity safety levels of
Sweden, we'd have one fewer babydying every single day.

(24:10):
And that would be amazing if we could get to that level.
They're one of the safest in Europe, but they they don't have
this very adversarial system. As soon as there's a tragedy,
you know, all that has to happenin Sweden is that the doctors
say there was a mistake. They don't apportion blame, but
they just say there was a mistake.
What was supposed to happen didn't happen and then the

(24:33):
family automatically get compensation and everyone can
concentrate on trying to understand what went wrong and
how to stop it happening again. And that is the kind of positive
learning culture that somehow weneed to get to in the NHS.
So finally, Victoria, what's arethe next steps?
Well, we do have this rapid maternity review that's looking
into maternity services in England.

(24:55):
Now it's being led by Baroness Valerie Amos and that is due to
report next spring. Now I, I, I feel conflicted
about it. I mean, I'm glad that the
spotlight is on it. But as we have said repeatedly
through this, there have been any number of reports.
Ockendon and to Shrewsbury and Telford was three years ago with

(25:15):
those urgent must do now recommendations.
How many of them have been takenup?
I don't know. I remember talking to Bill Kirk
up after Morecambe Bay and I said to him what if they don't
introduce these recommendations?What if they don't follow
through on them? And he looked at me aghast as if
to say well of course they're going to.
Well, then I saw him at East Kent some years later when he'd

(25:38):
just done that report and I said, well, what are you
thinking now? Because you wouldn't be here in
East Kent if they'd followed through on the recommendations
at Morecambe Bay. And that's the problem is we're
seeing what a very good reports into these scandals and then it
sort of seems to go into the ether now.
I'm sure there have been some improvements but because I am

(26:01):
still doing these stories, theseheartbreaking stories, you know,
not enough is changing as we've agreed here today.
Will another rapid review help? I don't know.
Will an A public enquiry? That's one of the other calls.
Again, I don't know if it will help, but something needs to
happen that is bigger and more than has been than has been

(26:24):
recommended so far. Thank you all very much indeed
for your time. Kaylee and and Jeremy, thank you
for joining us. That's the forecast for today.
Until next time, bye bye.