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Shrewsbury and Telford Hospitals Scandal Tells A Bigger Picture

Shrewsbury and Telford Hospitals Scandal Tells A Bigger Picture

By James Titcombe

Last week, upsetting news emerged about Shrewsbury and Telford Hospitals maternity services when The Independent newspaper published details of a leaked report written by maternity expert Donna Ockenden.

In 2017, the former Health Secretary, Jeremy Hunt, ordered a review of the cases of potentially avoidable harm at the trust following calls for an inquiry by the family of baby Kate Stanton-Davies, who tragically died in 2009.  The initial remit of the review was limited to 23 cases, however The Independent has revealed that the number of cases now being considered has grown to over 600, covering a period of time from 1979 to 2017 in what has been described as ‘the largest maternity scandal in NHS history’.

The leaked report identifies a number of concerning findings, including:

  • A long-term lack of informed consent for mothers choosing to deliver their babies in midwifery-led units – where risks can be higher if problems occur – which “continues to the present day”.
  • A lack of transparency, honesty, and communication with families when things go wrong. This supported a culture that was “disrespectful” to families who had been “damaged” as a result.
  • Failure to recognise serious incidents. Many families who had experienced tragedies were told they were the only ones, and lessons would be learnt. The report said: “It is clear this is not correct”.
  • A long-term failure to involve families in investigations that were often poor and described as “extremely brief” and “overly defensive of staff”.
  • A lack of kindness and respect to parents and families with multiple examples of deceased babies given the wrong names in writing or referred to as “it”.
  • Not sharing learning, meaning “repeated mistakes that are often similar from case to case”. Failure to learn was present from the earliest case of a neonatal death in 1979 to cases occurring at the end of 2017.
  • A lack of support for families who have “experienced significant loss and tragedy”.
  • A long-standing culture at the trust “that is toxic to improvement effort”.

Themes of this nature are not isolated to this trust and have been seen in national reports before.

Familiar Themes

In March 2015, the Morecambe Bay Investigation, Chaired by Dr Bill Kirkup was published. This report looked at the care and treatment of mothers and babies at Furness General Hospital between 2004 and 2013. The report described relationships between doctors and midwives as poor, and there was a repeated failure to learn from adverse events, meaning lessons were not learned, and similar failures were repeated.

More recently (November 2018), the Royal College of Obstetricians and Gynaecologist’s ‘Each Baby Counts’ programme published their second major report looking at the care of term babies who were either stillborn, died shortly after birth, or were at risk of brain damage in England in 2016.

The review found that 674 babies (71%) might have had a different outcome with different care. The main themes identified included ‘…failure by health professionals to identify or act upon relevant risk factors, issues related to monitoring of fetal wellbeing with CTG and blood sampling, and education or training issues.’

The report again highlights the quality of local investigations as a significant issue, finding that in almost a quarter of all cases, parents were not involved, or even made aware of reviews taking place.
The impact of each one of these tragic events on families as well as the health professionals involved, can’t be overstated.

The vast majority of professionals who work in our maternity service go to work to deliver the very best care they can. There is a need to address the causes of systemic failures like Morecambe Bay and Shrewsbury and Telford Hospitals – it’s vital systems are in place to support staff to provide safe care, and that a culture exists that ensures there is openness and learning when things go wrong.

Working together to improve maternity safety

There is no single solution to improving safety for mothers and babies. It requires a collaborative, transparent approach. We do know that investment in staff and high quality, multi-professional training is crucial across maternity services, and has been recommended by confidential enquiries spanning a few decades. In 2018, Baby Lifeline published detailed research that found that the provision of maternity training in key areas relating to avoidable deaths and injuries to women and babies was not prioritised, standardised or widely assessed. The major barriers identified were budget restraints and staff resource.

In 2016, the government launched an £8.1 m, ring-fenced fund to support multi-professional maternity training – a small amount compared to the annual cost of clinical negligence claims in maternity (the value of maternity claims received in 2017/18 was £2.1 billion, which is around £6 million a day). Baby Lifeline alone trained over 6,000 health professionals in the 12 months following the launch of the fund, with a fraction of the total amount released.

Despite a positive evaluation report commissioned by Health Education England (HEE) and repeated  calls from Baby Lifeline and others, this fund has not been repeated yet evidence shows the  crucial role training  has in the provision of  safer maternity care.

Baby Lifeline firmly supports The Independent’s campaign in calling for the next government to:

  1. Introduce a mandatory requirement on NHS organisations to involve patients or their families in investigations of incidents. Learning how to deal properly with clinical errors must also form a core part of undergraduate training for medical, nursing and midwifery students.
  2. Restore the £8.1m funding for NHS trusts across England as part of a Maternity Safety Training Fund which supported 30,000 staff to improve maternity safety in 2016. Despite a positive evaluation, this has been cut -the next government must commit to its reintroduction and expansion to cover all maternity units.

The emerging evidence relating to the scale and seriousness of the problems with maternity care at Shrewsbury and Telford Hospitals must result in an even more determined effort to ensure that hard working professionals are fully supported to provide the safest maternity care possible. We believe that the steps called for above would make a considerable difference, and we urge the next government to act.

4 Comments

  1. Dagmar Krueger 1 week ago

    Very true. Front line staff work hard for the safety, wellbeing and support of women, their babies and their families. There is no point in a review if it does not address what the patient perceived as wrong. Only they can express that. But that indeed needs trained staff. Because there is a fine line and dealing with very upset or emotional patients and staff as well as keeping service needs in mind is very challenging balancing act. There is a desperate need for longterm learning and systemic improvements, and the machinery that is the nhs is dauntingly difficult to change in aspects unless there is a team effort.

  2. Bernadette McGhie 1 week ago

    We need to take this opportunity to improve maternity safety and care. We cannot simply remonstrate time and again about how dreadful the situation is in a particular unit without taking steps to ensure that the same patterns of poor management and inadequate training are not repeated elsewhere. It’s not fair to mothers, babies and their families and it’s not fair to staff either who want to do no harm! There are some excellent maternity units let’s learn from them too.

  3. DR 1 week ago

    James, this is a very valuable piece. For me, primarily we have to look at how serious investigations are carried our and by whom. I would also ask these questions,
    – Who is it that investigates when a cover up can be identified?
    – Why isn’t there a national policy on when to refer to the coroner?
    – Is anyone looking at hierarchy on maternity wards – A junior registrar can seemingly run roughshod over midwives with 30 years experience?
    – Why is there no national policy on escalation?
    – Why are Trusts seemingly unable to control consultants?
    For me, we allowed the Trust to carry out a full investigation but it was carried out by the consultant in charge of maternity and the consultant in charge of care after birth in the NICU. The investigation was poor but the Trust are in denial.
    The coroner will deal with everything up to death but very little beyond. The CQC will look at systems and procedures, HSIB will look at the case but not the investigation. Who is it that has the authority to look at the entire case independently?

  4. Chris Rudland 1 week ago

    Well done James, valuable learning can be derived from SI’s if only the Trusts involved would engage with Families and Patients. So often we are excluded from all investigations and our valuable insight is forever lost. Keep doing what you are doing.

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