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.
The crux of the case was how efficiently concerns about lack of progress in labour were communicated to the medical team. However, these issues overlaid other problems. The midwife, who was said to be experienced, recorded that a syntocinon infusion had been started, but there was nothing in the notes to indicate if or when it was stopped when problems were suspected. The defence conceded pre-trial that it was not stopped until ‘JE’ (FE's mother) was taken to theatre at 3.00 am. The judge noted:
‘The midwife gave evidence that as far as she could remember it had, in fact, been stopped sometime much earlier than the time at which JE was eventually taken to theatre.’ (per McGowan J @ 8)
Not keeping an accurate record of drug administration, especially for a powerful drug such as syntocinon, is an elementary failure (Nursing and Midwifery Council, 2007). The judge continued:
‘The standard of record keeping was unsatisfactory, notwithstanding the workload… It is unacceptable that the administration of oxytocin is not properly recorded; the doctors should not be working on the presumption that it had been stopped simply because they would have expected it to be stopped.’ (per McGowan J @ 36)
Assuming that the syntocinon had been stopped presumably reduced the doctors' sense of how urgent the situation was. The midwife had documented at 1.15 am and at 2.00 am that she wanted an obstetric review in light of variable fetal heart rate decelerations. This was communicated to the labour ward coordinator, but the reply came back that the doctors were busy in theatre. The judge noted that the midwife
‘…was expressing an increasing level of concern in her notes and through the intermediary [i.e. labour ward coordinator]. That level of concern does not appear to have been communicated to or understood by [the doctors]. Whether that is the responsibility of the midwife, the intermediary or the doctors is difficult and unnecessary to determine. It was the case. If the doctors treating patient X did not or could not respond to the midwife's concerns then another senior practitioner should have been called by the midwifery team.’ (per McGowan J @ 36)
Every practitioner is aware of the health service having limited resources, and a busy night shift can put great strain on both people and systems; but when things go wrong is exactly when communication must be optimal, and when available resources must be used efficiently. Nevertheless, we know from repeated inquiries that, under pressure, communication between midwives and other staff is seen to fail (The King's Fund, 2008; Kirkup, 2015). In FE (2016), although the doctors knew that there was a problem, the seriousness of the situation was apparently not passed on to them by the labour ward coordinator. The judge also criticised one of the doctors for not leaving ‘Patient X’ (in theatre) as soon as it was practical to do so in order to review JE's care. Midwives working in busy obstetric-led units will recognise Pollard's (2011) reference to the importance of ‘power, gender, professionalism and the medicalisation of birth’ in UK maternity care. The doctor in question happened to be female, but we can only speculate whether this materially altered the power relationships that can exist between disciplines in busy units (the unit in question has nearly 5000 births a year).
‘All practitioners must feel able to communicate openly and honestly… the systems must be in place to allow—indeed, encourage—that to happen’
How, then, are such situations to be avoided in the future? Pointing out that all practitioners must feel able to communicate openly and honestly should go without saying, but the systems must be in place to allow—indeed, encourage—that to happen. Large maternity units are complex organisations, and those situated within even larger hospitals may be prone to occupational and hierarchical boundaries which, as Berridge et al (2010: 513) note, ‘contribute to care management problems with delayed recognition and poor response to clinical deterioration’.
Inter-professional undergraduate education introduces students from different disciplines to one another; continuing that theme of joint learning is vital if teamwork is to be effective, particularly when emergencies occur (Madden et al, 2011). This might be through skills training, emergency drills, or simply by developing a culture of mutual respect. Improving intra and inter-professional communication is necessary at the individual level, but may also be located in a unit's drive towards a ‘culture of safety’ (Burke et al, 2013), or the awareness that hospitals need to be ‘learning organisations’ (Dias and Escoval, 2015), or just because better communication results in better care and that results in higher satisfaction ratings by service users. Whichever (or whichever combination) it is, addressing the base cause of poor intra and inter-professional communication is vital.