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November 20th 2019

Birth Negligence

Horrifying findings of Shrewsbury and Telford maternity investigation must lead to greater scrutiny of deaths and injuries on wards across UK hospitals

Amanda Stevens

Amanda Stevens

Chief Executive Officer, Senior Solicitor

Horrifying findings of Shrewsbury and Telford maternity investigation must lead to greater scrutiny of deaths and injuries on wards across UK hospitals

The alleged catalogue of maternity care failings at Shrewsbury and Telford Hospital NHS Trust over a 40 year period is quite horrifying.

The alleged catalogue of maternity care failings at Shrewsbury and Telford Hospital NHS Trust over a 40 year period is quite horrifying.

However, I have to say that sadly the errors being highlighted only reflect those we continue to see costing lives and causing lifelong injuries on many other maternity wards across England and Wales.

According to media reports, a leaked update from an independent inquiry ordered by the Government into maternity care at the Trust, which runs Royal Shrewsbury Hospital and Telford’s Princess Royal, has highlighted a ‘toxic’ culture stretching back more than four decades.

It says that over this time babies and mothers have suffered ‘avoidable death’, whilst examples of shocking attitudes towards patients have been highlighted, such as routinely dismissing their concerns and even getting the names of dead babies wrong.

According to The Independent, which reported the situation last night having apparently seen a copy of the review update, the investigation singles out the deaths of at least 42 babies and three mothers between 1979 and 2017.

It says more than 50 children also suffered permanent brain damage after being deprived of oxygen during birth, as well as identifying 47 other cases of substandard care.  In total, more than 600 cases are now being examined, it seems with many more to follow.

Mistakes are often individual, but continued problems are collective

As a former hospital manager myself before embarking on a legal career which has seen me represent those so badly let down by the NHS, I am saddened, but ultimately not shocked by all findings in this report.

It is important to say that throughout my career, both as a hospital manager and a lawyer, I have never doubted the dedication, professionalism and empathy of front line healthcare staff who work tirelessly on wards across the country, as 99% show true dedication to their patients.

This certainly goes for maternity staff who individually go above and beyond to ensure the biggest moments in family lives – the addition of a new family member – goes as smoothly and positively as possible, despite the many challenges they face.

Yes, mistakes are made by individuals, but the problems and failings are collective.

This is often because of procedural failure, and when those errors are made, actions are not taken at trusts to learn lessons and prevent them being repeated.

The reasons for this are multi-faceted but when policy and decision making places greater focus on figures and reputational preservation it is plain to see how solving the underlying issues can end up on the back-burner.

Significantly, midwifery expert and chair of the investigation Donna Ockenden has identified that ‘failure to investigate and therefore failure to learn have been present in almost all of the cases’ in the report.

That is no surprise.

As always when scandals such as this emerge, the question has to be how this has been allowed to happen for so long.

The report highlights ‘substandard follow-up investigations’ into clinical errors that failed to ensure lessons were learnt.

It says bereaved families were treated with ‘a distinct lack of kindness and respect’ and warns that lessons are not being learned to date, with the trust being ‘uncommunicative with families.’

The report highlights errors we continue to see at many Trusts across England and Wales in 2019, including;

  • Babies left brain-damaged because staff fail to realise or act upon signs that labour is going wrong.
  • Failings in monitoring heartbeats during labour or failure to properly assess risks during pregnancy.
  • Babies left brain-damaged from group B strep or meningitis that can often be treated by antibiotics.
  • Families having to fight for answers around “very serious clinical incidents” for many years
  • A long-term lack of transparency, honesty and communication with families when things go wrong.
  • Not sharing learning, meaning “repeated mistakes that are often similar from case to case”.

Major investigations have repeatedly exposed shocking failings at UK Trusts

This leaked report says the failure to learn was present from the earliest case of a neonatal death in 1979 to cases occurring at the end of 2017, and it is this lack of accountability, openness and desire to learn lessons – which we see repeated across the NHS – which frustrates and angers me the most.

In our work supporting victims of medical negligence, we see first-hand how poor the NHS can be in its handling of cases involving families who lose loved ones due to negligent treatment and care.

We see cases where Trusts are simply focussed on protecting their own reputation, leaving bereaved families to face years of struggle to get answers as the try and battle through complicated and obstructive complaints procedures.

Even when apologies are made, and often damages settlements agreed, things don’t change.

Let’s not forget, the investigation into the deaths of 11 newborn babies and one mother at Furness General Hospital between 2004 and 20011 found a “lethal mix” of failings leading to a cover-up.

A similar culture was laid bare in 2013 by the public inquiry into the Mid-Staffordshire NHS care scandal, where an estimated 1,000 patients died between 2005 and 2009 as a result of poor care.

It was also a feature in the public inquiry into the children’s heart scandal in Bristol back in 2001.

Perhaps significantly, this report into Shrewsbury and Telford Hospital NHS Trust says that regulators were aware of problems as far back as 2007 when the Healthcare Commission highlighted concerns about injuries to babies.

However, it says the commission’s confidence the necessary improvements would be carried out was “misplaced”.

Sadly, hospitals are not prepared to fully scrutinize themselves, and industry regulators often don’t do enough. When major investigations have been ordered by the Government, shocking findings have been uncovered.

This latest scandal must act as a wake-up call to ensure much greater scrutiny is placed upon all trusts in relation to avoidable deaths and injuries on maternity wards.

We know it continues to happen to so many families at hospitals across the country, but not enough is being done to reduce the heartache, loss and devastation being caused.

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