Inquiry into blunders at hospital over seven baby deaths in 4 years
AT LEAST seven babies died needlessly at an NHS trust in a four-year period because of mistakes by medics, it emerged last night.
Health Secretary Jeremy Hunt has ordered an investigation after it was revealed that a failure to properly monitor heart rates played a contributory factor in five deaths, while another two were found to be suspicious.
Mr Hunt’s intervention at the Shrewsbury and Telford Hospital NHS Trust in Shropshire comes 14 months after a report found its two hospitals were among 21 nationwide with an infant mortality rate more than 10 per cent higher than the average.
Last night, one bereaved mother told of her anger at discovering staff had failed to monitor her daughter’s heart rate properly just ten days after a baby died when the same mistake was made. Tamsin Morris said her five-month- old daughter Ivy, who died in May from complications associated with her birth, would still be alive if the Trust had learned from its mistakes.
Mr Hunt has asked NHS England and watchdog NHS Improvement to review a series of deaths and other incidents at the Trust, which runs Telford’s Princess Royal Hospital and the Royal Shrewsbury Hospital. Most of the deaths occurred between 2014 and 2016, while one of the avoidable deaths took place as early as 2013, according to a BBC investigation.
Inquests or legal action against the Trust found that seven of the deaths were avoidable.
Kelly Jones delivered stillborn twins Ella and Lola in September 2014 after repeatedly telling medics she was in pain. The mother, from Monkmoor, Shrewsbury, said she was ignored and became so worried about her care she tried to discharge herself from the Royal Shrewsbury. But by the time staff took her seriously, the girls had died.
Miss Jones told BBC News: ‘The
‘They couldn’t be bothered’
midwife came in crying, saying I’m so sorry, I’m so sorry. My girls are gone because they couldn’t be bothered doing their job.’
An investigation by the Trust found that both babies died from oxygen starvation to the brain ‘contributed to by delay in recognising deterioration in the foetal heart traces and the missed opportunities for earlier delivery’.
In a letter to Miss Jones nine months after the twins’ deaths, the Trust promised that improvements would be made in the monitoring of baby heart rates. But two months later, Kye Hall died at the Princess Royal Hospital aged just four days. An inquest found the failure to listen to his heart rate at two critical times contributed to his death.
A monitor used in hospitals, called a cardiotocograph, can give an indication of how the foetal heart rate is responding to the stress caused by the mother’s contractions. It has been in use for decades but errors are still being made.
The Shrewsbury and Telford Hospital NHS Trust delivers about 4,700 babies each year. Its maternity services were severely criticised last year in an official report following the death of a baby in 2009.
The parents of Kate Stanton Davies had to fight for seven years to get the Trust to accept its failures had contributed to their daughter’s death after she was born at Ludlow Community Hospital, then part of the Trust. An investigation found there was a ‘lack of a safety culture’, that it had not held any staff accountable for Kate’s death and that lessons had not been learned.
The Trust says improvements have now been made and that mor- tality rates are in line with the national average.
Dr Edwin Borman, medical director at the Trust, said: ‘In the case of foetal heart rate monitoring, we have identified a number of cases where learning has not been fully implemented. We’ve put systems in place to make improvements.’
A Department of Health spokesman said: ‘The Health Secretary asked NHS regulators to undertake an investigation in light of disclosures that in a number of tragic cases standards of care fell far below those that parents would expect.’