Posted by Ali Cloak, Partner
Dozens of additional concerning cases identified at scandal-hit NHS maternity unit
On 31 August 2018 the Health Service Journal revealed that many more cases of concerning care have been uncovered at the NHS maternity service, which is already under investigation for 23 other cases where families have been failed.
The news that there are additional cases concerning deaths of babies, mothers as well as instances of life-changing injuries at Shrewsbury and Telford Hospitals NHS Trust maternity unit comes whilst the Trust is already subject to an investigation into substandard care.
The Health Service Journal (HSJ) reports there are now at least 60 separate cases including baby deaths, brain injury, and a number of deaths of mothers, all arising at the Shrewsbury and Telford Hospitals Trust.
In 2017, the then Secretary of State for Health, Jeremy Hunt, ordered an investigation into a spate of concerning events at the Trust. Senior midwife, Donna Ockenden, was appointed to review 23 cases of alleged poor care identified. This has become known as the ‘Ockenden Review’.
Since 2017, Shrewsbury and Telford Hospital Trust has undergone 6 distinct reviews to consider the quality of maternity care and at the time of writing at least 60 cases have now been identified, spanning a 19 year period so far.
The Trust’s former Head of Midwifery, was heavily criticised in relation to the death of baby Kate Stanton-Davies, and has subsequently been disciplined by the Trust for gross misconduct.
Separately, the HSJ reports that the Care Quality Commission (CQC) has threatened the Trust with formal warning. This was as a result of multiple safety concerns it has about the Trust, amid claims by its own staff that patients were being treated like “animals and cattle” in “unsafe, demeaning, undignified, and disgusting” conditions.
Lessons have not been learned
A Royal College of Obstetricians and Gynaecologists (RCOG) review published in July 2017 identified that mortality rates in the perinatal period (the period covering the latter stage of pregnancy and up to 1 year after delivery of the baby) were above average compared with similar trusts.
Perhaps even more alarmingly, it was noted that, despite deaths in 2013 and 2014, the RCOG previously found there was no “evidence of action plans and resulting changes in practice.” The spate of additional worrying cases which has come to light seems to be proof of this.
This is no doubt incredibly distressing for the families whose loved ones died or suffered catastrophic injuries at the Trust; suspecting that it could have been avoided if lessons had been learned from previous events at the Trust.
Rhiannon Davies, whose daughter Kate died at the Trust in 2009, says:
“What’s so difficult about what’s coming out is that things have been and continue to be far worse than even we knew.
Compounding this pain is the fact I now know acres of learning from avoidable deaths existed before Kate. Unlike what I was led to believe in 2009 Kate was not the first avoidable death at the trust. Yet no one bothered to learn and so sealed her fate – and mine, and that causes me almost unbearable pain.”
Families affected believe that the Ockenden Review should now be expanded to consider the emerging concerns, as well as those 23 originally identified.
The families have called for current Health Secretary, Matt Hancock, to broaden the terms of reference of the investigation to ensure these are included. His response is awaited at the time of writing this.
It is likely that the Ockenden Review will not be completed for quite some time, particularly if it is broadened to include a large number of additional cases.
I eagerly await the response of Health Secretary Matt Hancock, and the conclusions of the review. Hopefully thorough investigation and swift intervention at this stage can ensure that other families are spared the grief of a loved one’s death or suffering a catastrophic injury needlessly.
Where there is a pattern of substandard care then we hope that stringent mechanisms are put in place to address any gaps in learning, or any systemic failings. I hope that any staff who are implicated in any untoward events are held to account through their regulatory body, such as the General Medical Council or the Nursing & Midwifery Council.
The likely scale of the problems at Shrewsbury & Telford Trust could far exceed the likes of the Morecambe Bay scandal, in which failures were linked to at least 12 deaths of mothers and babies at Furness General Hospital between 2004 and 2012.
I sincerely hope that the investigation is independent and fearless, and that the families are heavily involved in the process. Their involvement is of paramount importance for ensuring the conclusions are fully informed and to maximise the opportunities for learning where things have gone wrong.
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