NEW MATERNITY DEATHS SCANDAL
The Mail, August 31, 2018 official letters, routinely dismissed the legiti- mate concerns of parents and falsely told them their cases were a one-off.
The report has been written by Donna Ockenden, a senior independent midwife who was tasked with looking into just 23 cases of poor maternity care at the trust in 2017. Her work was overseen by NHS Improvement, the health regulator, and leaked to The Independent.
Bosses failed to learn from their mistakes as they were ‘overly defensive of staff’, meaning failings were repeated year after year.
Several babies died or suffered life-long complications because midwives failed to properly monitor heart rates. Other were left brain damaged after they developed severe infections including meningitis that were not detected or treated with antibiotics.
Many families are still ‘ struggling’ to get answers from the trust over very serious clinical incidents dating back years.
One father received some feedback following his daughter’s death only when he bumped into a hospital employee in Asda.
Miss Ockenden wrote: ‘ These are real accounts about the suffering and grief experithis enced by individuals and families. Their experiences of maternity care should have been anticipated to be some of the most rewarding of their lives, but instead have often resulted in tragedy, that has continued to have long lasting and profound effects, to the current day.
‘As a result of these families coming forward, this review is now one of the largest the NHS has ever conducted into infant and maternal morbidity and mortality in a single service.’
She added: ‘ The number of cases we are now being requested to review seems to represent a longstanding culture at this trust that is toxic to improvement effort.’
Until now the biggest maternity care scandal was at the Morecambe Bay hospital trust, where up to 19 lives were lost.
Rhiannon Davies, whose daughter Kate died in 2009 following a series of failures by midwives, warned of an ‘ evil culture’ at the Shrewsbury and Telford trust that warrants criminal prosecution. ‘It’s no longer enough to say that lessons must be learned,’ she insisted. ‘History has proven that was never the case with trust, therefore, the only outcome that I will be satisfied with now is a successful prosecution of the hospital trust for corporate manslaughter.’
Dr Bill Kirkup, who chaired a major review into the Morecambe Bay scandal, said the new report made for ‘ghastly’ reading. But he warned that similar maternity scandals were being played out at other hospitals, unbeknown to the public. ‘Two clinical organisational failures are not two one-offs – they point to an underlying systemic problem that may be latent in other units,’ he said. ‘It is vital that we recognise why, and what we can do about it.
‘There is good evidence that some straightforward but farreaching measures would benefit all maternity units, as well as greatly reducing the chances of another large- scale disaster like these two.’
The final report into Shrewsbury and Telford is not expected until 2020 at the very earliest.
It is set to trigger major changes across all NHS maternity services. In July, the trust’s £160,000-a-year chief executive Simon Wright announced he was standing down, amid rumours he has been pushed out by NHS bosses. Mr Wright was meant to be taking up another role in a nearby health trust but he later confirmed he would be spending more time with his family.
Paula Clark, interim chief executive at the trust, said: ‘On behalf of the trust, I apologise unreservedly to the families who have been affected.
‘I would like to reassure all families using our maternity services that we have not been waiting for Donna Ockenden’s final report before working to improve. A lot has already been done to address the issues raised by previous cases.
‘Our focus is to make our maternity service the safest it can be. We have further to go but are seeing some positive outcomes.’
‘It makes for ghastly reading’