The Nature of Cultural Bias and its Implications for Clinical Negligence Proceedings

Recently, BBC News reported the tragic and untimely death of a 31-year-old pregnant Black woman at Liverpool Women’s Hospital1. The incident occurred in March 2023 and the nature of the woman’s death has sparked a charged conversation about cultural bias in clinical negligence cases. This article seeks to explore the nature of cultural bias and its implications for clinical negligence proceedings.

On 16 March 2023, a Black patient of Liverpool Women’s Hospital died, and the cause of death was recorded as:
1A. Acute intestinal ischaemia; and
1B. Thrombophilia
An independent investigation conducted by the Maternity and Newborn Safety Investigations (MSNI) found that the root cause was:

1. The lack of onsite surgical team and managing the patient in isolation and not ‘shared care’ with other acute specialties; and

2. The lack of co-location of LWH with acute trust. Further, it was reported that “ethnicity and health inequalities impacted on the care provided to the patient, suggesting that an unconscious cultural bias delayed the timing of diagnosis and response to her clinical deterioration”2, alongside challenges arising from low staffing and the junior doctors’ industrial action.

The MNSI investigation also found evidence of inaccurate and incomplete pain scoring as well as a failure to take some observations because the patient was ‘being difficult’. The clear disparities in her care have raised vexed questions about the adequacy of the care provided to the patient and concerns as to the role that cultural bias may have played in the diagnosis, treatment, or overall response to

1 BBC News Liverpool, ‘’Ethnic bias’ delayed care before Liverpool woman’s death’ www.bbc.co.uk/news/uk-englandmerseyside-68300655

2 Liverpool Women’s Hospital, Trust Board, 8 February 2024, https://liverpoolwomens.nhs.uk/media/5289/2024-02-08-trust-boardpublic-v1.pdf her medical needs.

This, unfortunately, is not an isolated incident. In an independent review of over 1,800 cases of neonatal deaths, stillbirths, maternal deaths and injuries to mothers and babies at the Nottingham University Hospitals NHS Trust, senior midwife, Donna Ockenden FRSA, has uncovered myriad examples of discriminatory and racist behaviour towards patients3. These cases arise in the context of research conducted by Mothers and Babies: Reducing Risk Through Audits and Confidential Enquiries UK (MBRRACE-UK) in January 2024 that found that between 2020 and 2022, Black women are over three times more likely to die during pregnancy or immediately afterwards than white women, and Asian women are almost twice as likely4. It is also worthy of note that disparities experienced by ethnic minorities go beyond maternal care, extending to mental health services, access to health services and genetic testing5.

Understanding Cultural Bias
Cultural bias as defined by the American Psychological Association is ‘the tendency to interpret and judge
phenomena in terms of the distinctive values, beliefs, and other characteristics of the society or community to which one belongs. This sometimes leads people to form opinions and make decisions about others in advance of any actual experience with them’6. Cultural bias causes us to make assumptions about a group based on our cultural background which then influences how we view and engage with said group. Cultural bias in healthcare refers to the influence of cultural factors on medical decision-making, treatment plans, and patient outcomes. It can manifest in various forms, from subtle assumptions

3 BBC News England, ‘Nottingham: New mums report racism in hospitals, says maternity lead’, www.bbc.co.uk/news/uk-englandnottinghamshire-68431157

4 MMBRACE-UK, Maternal mortality 2020-2022, www.npeu.ox.ac.uk/mbrrace-uk/data-brief/maternal-mortality-2020-2022

5 Kapadia, Dharmi et al. ‘Ethnic Inequalities in Healthcare: A Rapid Evidence Review’, NHS Race & Health Observatory (2022)

6 American Psychological Association https://dictionary.apa.org/cultural-bias to overt stereotypes that may impact the quality of care delivered. For example:

1. Queries around consent/miscommunication due to language barriers

2. A lack of understanding about how different illnesses/ diseases appear on darker skin

3. Myths around pain tolerance for ethnic minorities

4. Assumptions that some symptoms are more or less serious based on a patient’s cultural background

5. Differing levels of access to healthcare services

The case in Liverpool, and indeed other incidences of poor care in similar circumstances, demands our attention and reminds us of the urgent need for a comprehensive and systematic examination of cultural biases within the healthcare system. In addition, in order to address these concerns, hospitals and legal institutions should consider:

1. Representation in Medical Staff: 

Considering how diverse and representative is the staff body within the NHS, in particular, at decision-making levels and to what extent might the lack of diversity contribute to cultural bias.

2. Training Programs: 

Implementing ongoing training programs to raise awareness of implicit biases and provide healthcare professionals with the tools to address them.

3. Cultural Competence Standards:

Establishing and enforcing standards for cultural competence in medical diagnoses, treatment plans, and
overall patient care.

4. Legal cases:

Heightening an awareness of cultural bias in order to ensure it is properly accounted for.

As we grapple with the aftermath of this incident, it is crucial to confront the uncomfortable reality of cultural bias in the care of Black and minority ethnic patients. By raising our awareness of these issues, we can better understand the factors that might be at play in clinical negligence cases and better serve our clients.