Lucian Leape, a pioneer in patient safety, once said the single greatest impediment to error prevention in the medical industry is that “we punish people for making mistakes.” He was right. In my experience as health secretary, the biggest barrier to safer care in the NHS wasn’t a lack of expertise or dedication. It wasn’t – by the end – a lack of money or even clinicians. It was a blame culture that stopped people being open about mistakes. That prevents professionals from learning from tragedies and condemns the system to repeating them.
At the start of Baby Loss Awareness Week, we should remember that the number of tragedies remains heartbreaking. Including stillbirths, there are 4870 baby deaths every year in the UK – around 13 every day. Some of these would have happened with the best of care, but many more could have been avoided. And every single one leaves behind devastated parents who must do what no human being should ever have to do – bury their own child.
