Dear Sir
I am making this statement following the inquest into the tragic death of baby Jack Tually that concluded on 18th January. In doing so, I am fulfilling a promise I made last year. But before I begin I would again like to take this opportunity to publicly and wholeheartedly express my deepest sympathy to the parents. As I said after the verdict, I know that losing a child is every parent’s worst nightmare and I can’t imagine just how difficult it has been for the family.
From the beginning, the coroner made it clear that the purpose of the inquest was to establish the cause of death on the balance of probabilities and NOT to consider or offer an opinion on anything else. He reached his conclusions with the assistance of 3 expert witnesses in obstetrics, neonatal care and paediatric pathology. No other witnesses were called.
A narrative verdict was given, in which the coroner concluded that, on the balance of probabilities, the primary cause of death was hypoxia caused by Persistent Pulmonary Hypertension of the Newborn, or PPHN, a relatively rare, life threatening condition. Death was contributed to by the lack of effective intubation. No other factors contributed to the death.
As I said earlier, the inquest only dealt with the cause of death and it is for this reason the coroner decided to only hear evidence from the 3 expert witnesses. He made it very clear that this was expert OPINION but if evidence was required to be tested as factual, further witnesses would need to be called. Advocates were given the opportunity to request further evidence be heard but NONE did so.
What I can say now, is that 4 midwives and 2 doctors who were involved at the time were referred to their regulatory body in 2014. Both the General Medical Council and the Nursing and Midwifery Council investigated in accordance with their disciplinary procedures.
The GMC found no case to answer for one doctor. The other was required to retrain before they could return to practice. That doctor no longer works at the MSG and no longer has a licence to practice. The GMC completed their investigations in 2016.
In contrast, the NMC has taken years to conclude its investigation into the midwives, resulting in a constant drip, drip of media publicity and very public naming and shaming. It has also given the impression that their conduct contributed to the baby’s death when that was not the case. It’s also worth pointing out that there is still an appeal outstanding for one midwife, so matters have not even now, concluded.
I understand that the NMC has introduced a new approach recently that moves away from blame and punishment to learning from mistakes and preventing them from happening again. This change is welcome and I will speak more generally on that in a moment but I also hope it speeds the process up.
And that leads me to the time it has been taken for the inquest to be completed. Clearly 5 years is far too long.
However, I can categorically state for the record that, at no time, has there been any political interference or obstruction from the Committee for Health & Social Care in the coronial process. Neither have we, or previous Boards, ever covered anything up. It should also be pointed out that back in January 2016, 3 years ago, the expert witnesses agreed a consensus statement that the likely cause of the baby’s death was PPHN.
Members may also like to know that there are still 2 inquests outstanding that haven’t been opened, one from 2012 relating to a death that was investigated following the Tually case and one from 2016.
Therefore, on behalf of the Committee for Health & Social Care, I have written to the Policy & Resources President requesting that the Policy & Resources Committee consider whether any resources can be given to help reduce such delays happening in future.
Now, it is important to assure women and their families who are using maternity services that, contrary to what has been reported in the media, we provide an excellent level of service, which is comparable to the service that a small district general hospital in the UK would provide. Maternity services on Guernsey are able to give expert care to women who require both midwifery and obstetric care when either pregnancy or labour is not straightforward. We have in place a programme of care called ‘Every Baby Counts’, an evidence based tool that has been shown to reduce the number of stillbirths.
The maternity unit provides 24/7 obstetric consultant cover to ensure that women requiring medical help during their labour have access to this in a timely manner. A senior midwife is on duty 24/7 to coordinate the maternity service, both in the hospital and the community. There are now excellent midwifery staffing levels with at least 4 midwives on duty at any time. There is an on-call system in place so more midwives can be called in when the unit is busy. There are also 4 professional midwifery advocates who give midwives expert advice when required, and this has replaced the old system of midwifery supervision. There is training in place for all maternity staff, including doctors, midwives and health care assistants. There is now a robust system of clinical governance in place to ensure that HSC is an open and transparent learning organisation.
There will always be risks in healthcare, and HSC does everything it can to minimise these risks. But, very sadly, some babies are stillborn or die in the first few days of life.
We investigate and learn from all incidents, and last year implemented a programme of work called Safer Every Day, which uses the methodology of the International Institute for Healthcare Improvement, the world’s leading safety improvement organisation.
The stillbirth rate in Guernsey is lower than England and Wales at 2.9 per thousand births compared to 4.4. The number of infant deaths, is the same as England and Wales at 3.8 deaths per 1000 live births. Childbirth today is the safest it has ever been.
Let’s not forget that no one on that day exactly 5 years ago went to work wanting a baby to die. There was no malice aforethought. But there was a blame culture. And it was that which ultimately led to the failings found by the NMC. Midwives going outside scope as they felt unable to say no to verbal orders and the way the death was initially investigated reflected that. Everyone can, and must, learn from what happened. Everyone.
Matthew Syed in his book Black Box Thinking which I believe anyone involved in health and care should read, states, ‘Self esteem is a vastly overvalued psychological trait. It can cause us to jeopardise learning if we think it might risk us looking anything less than perfect. What we really need is resilience: the capacity to face up to failure and to learn from it. Ultimately that is what growth is about.’
A criticism often hurled at the States is that it needs to be more open and transparent. Indeed, it is essential that we own up to our mistakes if we are to constantly learn and improve.
However, if that is to happen, we as a community need to understand that we are all fallible and mistakes will happen. And nowhere is that understanding needed more than in healthcare with all the inherent risks that come with it. We all need to understand that compassion and tolerance are not a sign of weakness, but a sign of strength and our community will be stronger and more resilient for that.