When systems fail: An unhappy tale of a busy night shift

As if midwives needed any more reminding of the importance of good documentation and effective communication, there comes another court case which shows up failings in this regard. This article considers the case in the context of systemic approaches that try to address this problem.

In the recent case of FE (2016), the judge concluded that

‘Notwithstanding the pressures of a busy labour ward, the system of communication and the response to messages sent between the teams was inadequate and failed to ensure that a reasonable standard of care was provided…’ (per McGowan J @ 37)

Note that the judge, while still charged with establishing whether any individual practitioner had been negligent, referred to ‘the system’ being at fault. By ‘the teams’, she was referring to the midwifery and medical teams who were on duty one busy night in January 2001. The passage of time since the events in question should not cloud us to the fact that such failings have been found very recently in other inquiries (e.g. Kirkup, 2015). The failings are not unique to any one time or place, which makes their continued presence a systemic issue as well as a professional one (Healthcare Commission, 2008). Individuals can be encouraged or taught to improve their practice, but if the system in which they work is poorly structured then such failures become inevitable (Woodward, 2005). The fact that the failings in FE (2016) caused or materially contributed to another disastrous clinical outcome (the baby suffered neurological damage as a result of an acute hypoxic-ischaemic episode) is yet another reminder of how important it is to organise services so that effective care is facilitated. This includes communication between practitioners as well as high standards of clinical care.