19 August 2024

England’s Health Ombudsman has warned that women and babies are being put at risk after a worrying rise in the number of investigations about maternity care. 

The Parliamentary and Health Service Ombudsman (PHSO) is urging the Government and NHS leaders to learn from the mistakes being made and take action to protect more families from harm. 

In 2023/24 (1 April – 31 March) the PHSO investigated 87% more cases (28) about maternity care than the previous year (15). These are all cases which have already been investigated by the NHS and where they failed to address concerns. The Ombudsman recently closed a case in which it found a catalogue of failings by a hospital led to the death of a baby girl who was stillborn in December 2018.

In the cases investigated issues identified included delays to treating infection and carrying out an MRI scan, failing to manage an epidural during a caesarean, and lack of consent for a procedure. Since April 2020, PHSO has carried out 80 detailed investigations related to failings in maternity care. Investigations concluded in 2023/24 account for over a third of these. 

During that time the number of investigations upheld or partly upheld has also increased.

In March 2023, PHSO published a report about issues in maternity services. Common problems highlighted in that report include poor communication, and failings relating to diagnosis, aftercare, and mental health support.

Rebecca Hilsenrath, Parliamentary and Health Service Ombudsman, said:

“The rise in maternity investigations and the number of complaints being upheld over the last four years give rise to real cause for concern. It suggests that despite considerable investment in maternity care and well-publicised reviews into service failings, things are far from improving. 

“There have been successive inquiries and reports into maternity care and no real evidence of change. We need to see lessons being learned. Our 2023 report found the safety and wellbeing of women is being put at risk due to the same mistakes being repeated. 

“We know that there are brilliant practitioners out there.  But when maternity services fail, families are left with trauma and tragedy. The NHS needs to take steps to share good practice and change what isn’t working.”

In the recently upheld case, 33-year-old Carly Hardwidge, who lives in Chippenham, told clinicians seven times that she couldn’t feel her baby moving. She also repeatedly told midwives she was experiencing pain, contractions, water leakage and had blood-stained discharge. 

PHSO found staff at Royal United Hospitals Bath NHS Foundation Trust failed to properly investigate Carly’s concerns or refer her to an obstetrician on multiple occasions.

Rebecca Hilsenrath continued:

“The catalogue of failings by the Trust in this case is truly shocking and it led to the devastating loss of a baby.

“Once again, we see a patient’s concerns dismissed and not taken seriously. The lack of continuity of care meant nobody took a holistic view of what was happening. Ultimately, this led to the tragic avoidable death of a baby girl.”

Having previously had two miscarriages and pre-eclampsia, Carly should have been graded as high risk and placed under the care of a consultant.

She should have been referred to a senior consultant as early as September 2018 when she reported concerns about fluid loss for a third time. Carly should also have been referred to a consultant when she reported lack of movement for a second time in November.

These serious failings led to her daughter, Seren Browne, being stillborn. PHSO’s obstetrics adviser said the likely cause of death was infection caused by a slow leak of the water surrounding Seren. 

Carly, who has four children, but says she will always be a mother-of-five, said: 

“I was never listened to or taken seriously by the hospital staff. It has affected my mental health and still massively affects me, my partner Haydn, and our other children. 

“We didn’t lose a baby, we lost a whole life; her first steps, her first words, her first day at school, which would have been last year. Every day there is a constant reminder of Seren and what might have been. There are so many what-if questions – what would she look like now, what would she be doing?

“For years I blamed myself. I was the one who carried her. I’m the one who was meant to keep her safe. Now I have it on paper that if I had been listened to my daughter would be here today. Seren would be playing in the park, eating ice cream and causing chaos with her siblings. Instead, she’s at home in an urn on the shelf.

“If more people were listened to and taken seriously, this would not keep happening. That’s where I get my strength from, despite everything, I fight every day for justice for my daughter.”

Alongside the clinical failings, staff’s attitude and behaviour fell well below professional standards – an issue previously highlighted in national reviews of maternity services. The Trust’s bereavement care was also below what is expected. 

The Ombudsman recommended that the Trust acknowledge its failings, apologise, and set out what it will do to prevent the same mistakes happening again. 

The Trust was also told to pay £1,000 to recognise the impact the failings in bereavement care and complaint handling have had on the family. This amount only relates to those issues. The failings in antenatal care have been referred by the Trust to NHS Resolution to agree a compensation award with Carly.

A spokesperson for the Royal United Hospitals, Bath, said: 

“We are deeply sorry for the tragic loss and emotional distress experienced by the family.  

“We apologise for the failings identified and fully accept the recommendations of the Parliamentary Health Service Ombudsman.  

“We all strive to provide excellent and safe care for women, birthing people and their babies and when harm happens, we spend time reflecting on and learning from what we could have done differently. 

“We have made changes in response to this case, including training in relation to carrying out risk assessments and identifying when to refer to consultants and embedding a communication and escalation tool kit.”

 

Between April and June 2024, the Human Rights Ombudsman of the Republic of Slovenia (Ombudsman) considered various complaints from people who contacted him in connection with ensuring the human rights of persons with disabilities. He helped complainants with explanations about their rights and legislation, addressed recommendations to the competent authorities for better realisation of rights, and publicly drew attention to the rights of persons with disabilities. The following is an overview of completed consideration of complaints and various public activities.

The Ombudsman warned of delays in deciding on rights under the Social Inclusion of Persons with Disabilities Act

The Ombudsman notes that there are still delays in deciding appeals against decisions on rights under the Social Inclusion of Persons with Disabilities Act. A complainant who turned to the Ombudsman in this regard has been waiting for a decision for more than a year, and the Ministry of Labour, Family, Social Affairs and Equal Opportunities (MDDSZ) is dealing with several other complaints in which the deadline for a decision has already passed. (more in Slovene)

The Ombudsman was critical of the unannounced visit of an expert doctor for a personal examination at home

A complainant turned to the Ombudsman complaining about the lengthy decision-making process of the Maribor Regional Unit of the Institute for Pension and Disability Insurance of Slovenia (Institute) on her request for recognition of the right to allowance for assistance and service. In relation to the consideration of her request, the complainant explained that she had received a notification from the Institute that an expert doctor, who was supposed to carry out a personal examination of the complainant, had visited her twice at her home. The complainant claimed that the expert doctor's visit had not been announced and that she was unable to open the front door due to her health condition, and the said unit of the Institute subsequently asked her in writing to explain the reasons why she was not at home, and that if at the next visit of the expert doctor she is not at home, the procedure would be stopped. The Ombudsman assessed the conduct of the Maribor Regional Unit of the Institute for Pension and Disability Insurance of Slovenia in the event of an unannounced visit to the complainant as a violation of the principle of good management. In addition, the Ombudsman found that, in the case of the complainant, the statutory deadline for decision-making had been exceeded and thus a violation of the principle of legality. (več)

Problems in placing a child in a vocational institution

The Ombudsman received a courtesy copy of a letter from the district court, with which the MDDSZ and the Council of the Republic of Slovenia for Children and the Family were informed of the problems with imposing a measure of a more permanent nature by placing a primary school child in a regionally competent professional institution. The court stated that in the specific case, the elementary school child had to be taken out of an environment harmful to him and placed in a professional institution in the next school year (2023/2024). Before the hearing (which was scheduled a good week before the start of the new school year), the professional institute announced that it was fully booked and that it could not accept the child. After receiving the response from the Ministry of Education (MVI), the Ombudsman concluded the consideration of the specific complaint, as appropriate accommodation was found for the child at risk in time. However, since this was not the only complaint to the Ombudsman that highlighted problems with the placement of children and adolescents under the Act on the Placement of Children and Adolescents with Emotional and Behavioural Problems and Disorders in Education and Training (ZOOMVI), the Ombudsman continues to address the aforementioned issue. It is unacceptable that, due to a lack of capacity and personnel, the state would forget its duty to ensure the greatest benefit of children by leaving them in dangerous environments. (več)

The National Preventive Mechanism also visited work and centres between April and June

In April and May, a representative of the NPM[1] visited the residential unit of the Bohova Care and Work Centre (VDC) Polž and the residential units of the Novo mesto VDC in Trebnje and Novo mesto. In June an NPM representative visited four units of the Matevža Langusa Radovljica Centre for Education, Work and Care (CUDV).

The Ombudsman met with the Ombudsman for the Rights of RTV Viewers and Listeners

Today, 20 June, Ombudsman Peter Svetina welcomed the Ombudsman of Radiotelevision Slovenia Marica Uršič Zupan. She presented him with the key findings from the annual report for 2023. The Ombudsman emphasised that, despite progress in ensuring accessibility, there are unfortunately still quite a few shows that are subtitled for the deaf and hard of hearing only when repeated or to be viewed later on the website, which puts the deaf and hard of hearing in an unequal position. In the conversation, Ombudsman Svetina praised the efforts of RTV Slovenia to improve the accessibility of content for people with sensory disabilities and highlighted the importance of ensuring equal access to information and programmes for all viewers. He added that he strongly supports the initiative of disability organisations, with which they are trying to have RTV Slovenia broadcast the 2024 Paralympic Games in Paris.(več)

The Ombudsman organised a consultation on deinstitutionalisation

On 29/05/2024, the Ombudsman organised a consultation in Nova Gorica entitled Deinstitutionalisation – a Necessary Process for Ensuring Human Rights. In the first part of the consultation, Ombudsman Peter Svetina talked about the questions of where we are and where we are going in the field of deinstitutionalisation with professor at the Faculty of Social Work Vito Flaker and with the director of the Nova Gorica Retirement Home, Bojan Stantet. In the second part of the consultation, Deputy Ombudsman Dr. Dijana Možina Zupanc led her interlocutors through reflections on opportunities and challenges in practice. At the end of the consultation, the participants adopted conclusions and formulated recommendations. (več)

At the Conference of States Parties to the Convention on the Rights of Persons with Disabilities, the Ombudsman addressed the opportunities and challenges brought by artificial intelligence

Ombudsman Peter Svetina participated in the 17th session of the Conference of States Parties to the United Nations (UN) Convention on the Rights of Persons with Disabilities (COSP17 – CRPD), which was held in New York between June 11 and 13. The running theme of the session was a rethinking of the importance of including persons with disabilities and the search for international consensus on how to provide them with a better present and protect their future. At the meeting, he actively participated in the general discussion. Since one of the sub-themes of the conference was international cooperation to promote technological innovation and technology transfer for an inclusive future, he focused in his address on the advantages, challenges, and risks of artificial intelligence on the rights of persons with disabilities. He also made the statement on behalf of the Working Group on the Rights of Persons with Disabilities of the European Network of National Human Rights Institutions (ENNHRI), which brings together more than 38 European national human rights institutions. (več)

The Ombudsman organised an international webinar on artificial intelligence and the rights of the disabled

On 22 May 2024, the representative of the Ombudsman Jerneja Turin, who chairs the working group for the rights of persons with disabilities within the European Network of National Human Rights Institutions (ENNHRI), organised a webinar for the members of the working group and other interested representatives of national human rights institutions on artificial intelligence and its impact on the rights of persons with disabilities. The aim of the seminar was to enable participants to understand how advances in artificial intelligence technology can affect the rights of people with disabilities. With the help of expert presentations and an open discussion, the participants examined the potential challenges, risks, and opportunities related to the implementation of artificial intelligence in the context of the rights of persons with disabilities and the possible role of national human rights institutions in dealing with related risks and challenges. (več)

Ombudsman for health and social care trade unionists on human rights

On 12/04/2024, the Health and Social Care Union of Slovenia prepared a professional training session in Ankaran, at which Ombudsman Peter Svetina spoke about human rights in health and social care activities. He emphasised that when caring for people, whether it is covered by long-term care or personal assistance or other forms, special care must be taken to ensure that the system is designed in such a way that no one fall out of it in the end. He also stressed that everyone has the right to live in the environment in which they grew up. He assessed the recent adoption of the deinstitutionalisation strategy as a first step in the right direction, but without a concrete and feasible action plan, an appropriate legislative framework, and, above all, funds, it will not be enough if we want to establish an accessible, efficient and financially sustainable system of long-term care, which will be based on social justice and intergenerational solidarity. He also informed those present that the institution of the Ombudsman is also dealing in more detail with the accessibility of the environment, public transport, and communications for the disabled, and pointed out that when dealing with the alleged unresponsiveness of the Construction Inspectorate to reports of architectural obstacles, we discovered systemic irregularities in the Equalisation of Opportunities for Persons with Disabilities Act. (več)

On the Slovenian day of Paraplegics and Tetraplegics, the Ombudsman warned of discrimination and problems with personal assistance

On the occasion of the Slovenian Day of Paraplegics and Tetraplegics, the Ombudsman drew attention to the problems he perceives in relation to personal assistance and appealed to the decision-makers to ensure that the amendment to the Personal Assistance Act provides adequate legal regulation of the field of personal assistance, whereby the rights of individuals should be equally protected and individuals enabled to effectively enforce legal remedies. The Ombudsman emphasised once again that the guideline for amending the Personal Assistance Act must in no way be based on the assumption that it is an abuse of the current arrangement, but on ensuring the need for assistance to those entitled individuals who cannot be equally included in society due to disability. In a statement to the public, the Ombudsman also warned that, unfortunately, discrimination against persons with disabilities is still evident in many areas in Slovenia. (več)

On International Easy Language Day[FT1]  the Ombudsman warned about the right to information in an easy-to-read format

On the occasion of International Easy Language Day, Ombudsman Peter Svetina emphasised that an inclusive society is built by respecting the human rights and fundamental freedoms of everyone. If we really want to be such a society, we must also learn to prepare information in an easy-to-read format. (več)

On the occasion of International Autism Awareness Day, the Ombudsman warned about the insufficient implementation of the integration of people with autism

The Ombudsman estimates that education about autism and specific approaches based on the needs of people with autism must be one of the key elements in action plans for integration. For many years, the Ombudsman has been approaching decision-makers with proposals to prepare systemic programmes that would allow for an increase in the number of professionals for expert work with people with autism and their families, and with other measures to make available the regular treatments and therapies that people with autism need. He has not seen any progress. He estimates that the implementation of the integration of persons with autism in Slovenia is insufficient. The Ombudsman points out that autism is a lifelong condition, so it is necessary to pay special attention to the systemic regulation of care for adolescents and adults with autism. As they transition into adulthood, they are left to the ingenuity and possibilities of their families. Despite the fact that this is an obligation of the state, it does not provide programmes that would enable suitable accommodation in which people with autism could exercise their right to live independently, and there is also a lack of properly trained professionals who could support adults with autism in their independent life. (več)

The Ombudsman published his regular annual report

In June, the Ombudsman submitted to the National Assembly the 29. redno letno poročilo Varuha človekovih pravic in 16. poročilo Državnega preventivnega[FT2]  for 2023, which, among other things, also deals with the human rights of persons with disabilities, and personally handed the documents over to the President of the National Assembly of the Republic of Slovenia Mag. Urški Klakočar Zupančič, Prime Minister Dr Robert Golob and predsednici Republike Slovenije dr. Nataši Pirc Musar[FT3] . In 2023, the institution of the Ombudsman handled a total of 6,225 cases, which is 250 cases more than the year before, and found 262 violations of human rights and fundamental freedoms and other irregularities. The authorities still most often violate the principle of good governance (in 2023, this was the case in 65 cases), unjustifiably delay procedures, and violate the principle of equality before the law and the rights of persons with disabilities. This is followed by violations of the right to social security, violations of the right to healthcare, and violations of the principle that Slovenia is a legal and social state. (več)

Previous reviews of the Ombudsman's activities in the field of the rights of persons with disabilities (clicking on the indents below will take you to the place where they are published):

-        januar-marec 2024

-        oktober-december 2023

-        julij-september 2023

-        april-junij 2023

-        januar-marec 2023

-        oktober-december 2022

-        julij-september 2022

-        april–junij 2022

-        januar–marec 2022

-        oktober–december 2021

-        julij–september 2021

-        april–junij 2021

-        januar–marec 2021

-        oktober–december 2020

-        julij–september 2020

[1] The task of the Državnega preventivnega mehanizma (which was established within the framework of the  Ombudsman based on the request of the Optional Protocol to the Convention against Torture and Other Forms of Cruel, Inhuman or Degrading Treatment or Punishment) is to visit places of deprivation of liberty in the country and check the treatment of persons deprived of their liberty, with a view to strengthening their protection against torture and other forms of cruel, inhuman, or degrading treatment or punishment.

 [FT1]www.easy-plain-accessible.com/international-easy-language-day-28th-of-may-2020/

 [FT2]29th Regular Annual Report of the Human Rights Ombudsman and the 16th report of the National Preventive Mechanism

 [FT3]President of the Republic of Slovenia Dr Nataša Pirc Musar

Photo gallery (1)

Desde la institución se pretende analizar y garantizar el bienestar de las personas residentes

La Diputación del Común ha tomado medidas activas en respuesta a las peticiones recibidas por parte de varios familiares y de la Plataforma online SOS Barrios Canarios sobre el funcionamiento del Hospital Residencia de Ancianos Nuestra Señora de la Concepción de Garachico. Tanto la Diputada del Común, Lola Padrón, como el adjunto primero de la institución, Antonio Alarcó, han elevado la petición de información tanto al ayuntamiento de Garachico como al Instituto de Atención Social y Sociosanitaria (IASS) del Cabildo de Tenerife. Igualmente se ha solicitado a la Viceconsejería de Bienestar Social de una inspección exhaustiva del centro.

Las preocupaciones mostradas por los familiares refieren que no hay personal suficiente para atender a sus mayores, que los encontraron sucios, sin cambiar los pañales y sin asear para poderles sacar a pasear, y el hacinamiento de hasta 8 personas en una misma habitación, entre otras cosas. Otros familiares, insistieron en la falta de personal y hacinamiento, y narran que su madre fue hospitalizada por contagio de sarna entre febrero y marzo del presente año pasado. Confirmándoles el personal del centro que se habían producido hasta tres brotes desde el periodo que va de diciembre de 2023 a junio de este año. También aseguran encontrarse con la ropa de cama y su vestuario manchado de orines y heces.

Por su parte la plataforma online SOS Barrios Canarios también elevó una solicitud a la Diputación del Común donde se solicita que se pida al Cabildo de Tenerife, IASS y Servicio Canario de la Salud “que intervengan y envíen personal suficiente para la atención a los pacientes grandes dependientes”. Cuentan que hay 75 pacientes con diferentes grados de dependencia y que además los trabajadores y trabajadoras necesitan protección dada la carga de trabajo y esfuerzos realizados.

La diputada del Común, Lola Padrón ha insistido en preguntar a las instituciones si conocen la situación actual del centro, “en particular, en lo que se refiere a la dotación de personal para atención, cuidado y medidas terapéuticas a los grandes dependientes y si la residencia cuenta con las infraestructuras y equipamientos necesarios”.

Ante la falta de respuesta a las peticiones de información cursada por la ciudadanía, la Diputación del Común ha reiterado su petición, “subrayando la urgencia de obtener una respuesta clara”, según asegura el adjunto primero, Antonio Alarcó.

Padrón, remarcó que “es preciso que haya una dotación de personal y unas infraestructuras adecuadas de los centros, con especial énfasis en la atención a los grandes dependientes”.

Commissioner for Fundamental Rights of Hungary Dr. Ákos Kozma and Deputy Commissioner for Fundamental Rights, Ombudsman for the Rights of National Minorities Dr. Elisabeth Sándor-Szalay launched a joint inquiry in 2023, in order to get a comprehensive view of the national minority-related contents of the cultural institutions. As part of this inquiry, several on-site visits took place in the past few months, where the regulatory frameworks and the possible ways of the practical implementation of the rules were discussed, among others.  

On 17-18 June 2024, invited by the Slovenian community, the Commissioner for Fundamental Rights of Hungary and the Deputy Commissioner for the Rights of National Minorities paid a visit to Vas County, where they first of all got acquainted with the cultural values of the Slovenian and Croatian national minorities and also visited the main cultural institutions of these communities. During the visit, the Ombudsman and his deputy conducted professional coordination talks with the elected leaders and cultural experts of the Slovenian community, as well as the staff members of the museums.

The event was attended by Slovenian nationality advocate Mrs. Kiss-Köles Erika and President of the National Slovene Self-Government Mr. Károly Holecz.