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The Tinkerman continues his pursuit of safety. He's moved on to baby births and deaths.  Quite right.

Concerns go back to 2011; evidence of our poor performanceWe rate 33rd out of thirty five countries.  It looks to me like something is very wrong.  Wrong with the numbers or wrong with the services.  Which is it?

An MBRRACE-UK audit tells us 4 in 5 baby deaths might have been avoided.  In 36% of cases, shortages of staff, or space in delivery rooms were key factors.

This is a minefield.  An explosive cocktail of grief, bereavement, blame, despair, money, resource, careers, compensation and the law.  It doesn't get anymore complicated.

Part of the plan is to move to a rapid resolution and redress scheme, avoiding the courts.  Critics say it will 'rob' families of compensation.

In 2016, maternity negligence claims were £1.4bn, plus.

Compensation arrangements date back to 1948.  When the NHS was set up, it was fiercely opposed.  Part centred on, what if the 'the state' failed to provide good enough care.

The solution was to guarantee the right of citizens to sue the NHS.  Compensation based on the assumption on-going care would be provided by the private sector.  Litigants, once 'damaged' by the NHS, were though unlikely to trust it with further care.

Over the years compensation has spiralled.  No-win-no-fee arrived...  an argument is developing that awards should be made on the basis of the NHS providing ongoing care.  The private sector has scarce capacity to provide for complex needs.  Invariably the NHS provides.

A balance between what's fair and what's affordable, in days very different from 1948, won't be easy.

How do these terrible events happen?  If our care is so much worse than other countries, what's to be learned from them?  Has anyone gone to find out?

From next April investigations will be undertaken by the HSIB and there's the prospect of new legislation to allow coroners to investigate full-term, still-births.  Plus... more targets. 

How difficult is it to monitor a baby's heart rate?  I have no idea.

You can buy the kit and do it at home

... but people say don't, because you won't know what it tells you.

Intermittent auscultation or continuously electronic foetal monitoring doesn't seem too difficult? Listen to a baby's heart rate for one minute after a contraction, every 15 minutes during the early stages of labour, increasing to every five minutes or after every contraction in the later stages.  Why not?  I have no idea.  I'm not a midwife.

I'm mindful of Florence Nightingale:

"What cruel mistakes are sometimes made by benevolent men and women in matters of business about which they can know nothing and think they know a great deal."

Catastrophic errors are seldom caused by catastrophic issues.  They are caused by the alignment of little things that get overlooked.  Workplace habits, not enough midwives, poor communication, confusion, not enough kit, not calibrated, damaged... no one noticed?

If a midwife relies on experience, not readouts, if a heartbeat is misheard or misinterpreted...

I was talking to an airline pilot about safety.  He laughed when I said we try and emulate the airline industry.  He said; 'I fly safe because I want to get home in one piece, that's all.'

He's right.  If a surgeon, midwife, dentist or nurse makes an error, they still go home.

David Buchanan and Ciara Moore have written persuasively about managing and learning from incidents.  They tell us, 'staff are often shocked when [events] happen'.  Given the weight of regulatory pressure how surprised are we that, post-event, they close-up.  

How do we persuade staff to become more than witnesses?  Mind-shift them from 'cause' to 'why'?

In my experience, staff know why errors occur.  If the climate is right, they will tell you, help you find them and fix them, fast. 

Reports, investigations, process and litigation all come too late.  As Buchanan and Moore say;

'Create an expectation of rapid post-incident change, not dependent on the outcomes of formal investigations.'

They're right and I'm really not sure we are going about this in the best way we could.

There is a welter of best practice guidance, training, tool kits, protocols, regulation and supervision.  We know what to do, yet high stakes errors, mistakes committed with high confidence still happen.

Analysis of reasoning and procedures leading up to serious incidents reveal they are almost always system errors,  Buchanan tells us; system fixes must be tailored to local circumstances.

We would do well to listen.

Have a good weekend.

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