Birth, sweat and trauma: why don’t doctors learn from their mistakes?

 

Lotty’s labour was long and painful, and she eventually gave birth to her daughter by forceps. It was a difficult and traumatic experience, but it didn’t end there. Mistakes made by the medical team during her labour meant that a few weeks after giving birth, Lotty nearly died. I don’t want to give away her story, but you can listen to her recount it in this new podcast from The Backstory, part of a series that talks to people about their personal struggles and tragedies.

The story Lotty tells so movingly is her own, and has its own unique elements. I’ve heard lots of stories of traumatic births now, but none has been exactly the same as Lotty’s. And yet there are so many common features to these stories that I start to tick them off as I hear them

  • Multiple medical mistakes – tick
  • Fobbing off the woman’s concerns that something is wrong – tick
  • An unwillingness to explain the problem properly – tick
  • Attempts to minimise the gravity of the situation – tick
  • A lack of compassion and sensitivity – tick
  • The non-apology apology when your mistakes have nearly killed a patient: “I’m sorry you felt upset…” – tick

It’s not that I don’t value the work that obstetricians and midwives do. Lotty was in so much pain during labour that she bit the midwives, which can’t be a lot of fun – most of us, however annoying we find our work, don’t expect to be bitten. And labour is a difficult and unpredictable business – it’s not surprising that in a stressful, rapidly changing situation, mistakes are made.

BUT. The mistakes made by the health professionals looking after Lotty were easily avoidable. They were basic errors of care. If a simple checklist had been followed, the problem that ended up nearly killing Lotty could have been identified and dealt with immediately.

To make it worse, no-one listened to Lotty when she told them something was wrong. When they finally did something about it, they all – apart from one doctor, an old schoolfriend – refused to acknowledge the seriousness of the problem. And when she did finally complain, they pretended that it was her fault for being irrationally upset, not their fault for nearly killing her.

Does it have to be like this?

As I mentioned in my last post, the new Healthcare Safety Investigation Branch will investigate cases of stillbirth and severe brain injury as a result of birth. It won’t, however, investigate mistakes that lead to less serious outcomes. And yet what cases like Lotty’s show is that mistakes that lead to near-misses should be reviewed and learned from. The response when a patient nearly dies as the result from an error shouldn’t be, “Sorry you feel upset about this” but “We made a mistake. What did we do wrong – and how can we stop it happening next time?”

Even better would be if each maternity unit gathered the data on its mistakes and shared them nationally so every other maternity unit could learn from them. There are 700,000 births a year: imagine what a rich data set that would provide. Imagine how much better we could make birth if we learnt from every incident of a birth going wrong.

Until that’s in place, stories like Lotty’s – and stories that have a much more tragic outcome – will keep on happening.

 

 

 

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