Not just incompetent ... almost inhuman
As 200 MORE families come forward in the Shrewsbury maternity scandal, this shocking investigation reveals how medical blunders were compounded by a breathtaking lack of compassion for the grieving ...
PICTURE this heartbreaking hospital scene: a grief-stricken family is gathered round a newborn baby girl who does not have long to live following complications during her delivery. There are tears, so many tears, and anguished cries, as relatives say their final farewells and wait for the end to come — which it does soon enough.
Just hold that image in your mind for a moment. Then, if you can, try to comprehend what actually happened next, when a member of the maternity staff approaches the infant’s distraught loved ones. No words of comfort or sympathy are forthcoming. Instead, the devastated mother says: ‘We were told that if we didn’t keep the noise down, we’d have to leave.’ It’s unbelievable, isn’t it?
Except the shocking testimony of ‘Mother 19’, as she is referred to, is there, in black and white, in the report into the catastrophic failings of baby units run by Shrewsbury and Telford Hospital NHS Trust (SATH). Part of the report was leaked last week, but the cruelty shown to the bereaved by the Trust has gone largely unreported — until now.
More than 600 cases of potentially substandard care were identified. Already we know there have been 45 avoidable deaths — 42 babies and three mothers — and 51 instances of brain damage or cerebral palsy in infants in what is believed to be the NHS’s worst ever maternity scandal.
In the wake of the media coverage more than 200 new families have come forward. ‘Many of them are people who lost babies at the hospital and I understood that the hospital had passed on the information to Donna Ockenden’s inquiry [Ockenden is the senior independent midwife who is chairing the review],’ said Kay Kelly, head of clinical negligence at London law firm Lanyon Bowdler, which is handling some of the latest cases.
West Mercia police are liaising closely with the Ockenden team and criminal charges, including corporate manslaughter, may yet follow.
It’s hard not to believe, though, in the light of a seemingly unending list of potential victims still emerging, that the avoidable death toll, already horrifying, will not rise even further.
THE chilling facts are shocking. But buried in the detail of the small print, so to speak, of the Ockenden report, is the casual inhumanity which lies behind each death, each ruined life, each family.
Such as the experience of Mother 19, who recently gave evidence to Ockenden about how her daughter died on the day she was born ‘following a brain injury sustained secondary to birth trauma’.
‘You never get over it,’ she says. ‘It’s something you learn to live with on a daily basis. It changes you and your whole outlook on life. You’re not the same person any more.’ To be told to ‘keep the noise down’ in these circumstances is beyond insensitive.
Afterwards, staff compounded her distress by losing her baby’s precious blanket and shawl. ‘I never got them back,’ she adds. Mother 19 then describes having to ‘push’ the Trust to conduct a ‘serious incident review’ but has never been informed if it was ever carried out.
Too many of the bereaved have similar horror stories. Father 7, whose baby died not long after being born, recalls how he was crassly advised by a member of the maternity staff that ‘the way to get over this is to try again, go and have another baby’.
Understandably, this prompted a furious reaction from Father 7.
‘They had to physically remove me from the room because I was going to choke X [the staff member in question],’ he recalled.
Father 3 received no information about the death of his daughter. The only feedback was when ‘I bumped into X [an ex-employee of the Trust] in Asda,’ he says in the report.
Some deceased babies, meanwhile, were referred to as ‘it’. Others were given wrong names, frequently in writing. One family was unable to say a ‘final goodbye’ because, horrifyingly, their baby’s body had been allowed to decompose following a post-mortem. How can this happen in a civilised country?
Let’s begin with the tragic story of stillborn baby Thomas Gough at the Royal Shrewsbury Hospital in 2001.
Doctors tried to resuscitate him but, after half-an-hour, were forced to declare him dead. His parents were told this was because their son’s umbilical cord had become twisted around his neck.
Later, however, they discovered the truth from his medical records which showed there were warning signs throughout his mother’s labour that were never picked up.
The tragedy, in other words, was avoidable, a word that crops up again and again in the Ockenden report.
The family sued the Trust and were awarded £50,000 in compensation, although the legal action was never about money. ‘Thomas should never have died and our lives would not have been shattered,’ his mum Vicky said at the time.
Thomas’s death is significant. The list of the ‘Shrewsbury and Telford’ victims might stretch back as far as 1979 but the death of Thomas Gough nearly two decades ago is believed to be the first which attracted publicity, in the local Sunday Mercury newspaper.
What happened to him — clinical mistakes followed by obfuscation and cover-up — would become an all too familiar pattern of behaviour in the years that followed.
If lessons had been learnt then, it is possible other lives — among them Cameron Dickens-Smith and Abbie Louise Everitt, born two weeks apart in 2004 at the Royal Shrewsbury — would not have been lost.
Both Cameron and Abbie were left severely brain damaged after being deprived of oxygen at birth.
AT LEAST 51 of the cases now being investigated in the Ockenden review involved babies left with brain damage or cerebral palsy like Cameron and Abbie.
‘We can’t comment on individual cases,’ a Trust official told the Birmingham Mail at the time but readers were assured there were ‘robust systems in place for the training of staff and we regularly have external validations of these systems’.
The subsequent inquiry by the Healthcare Commission (now the Care Quality Commission) found there ‘were areas of concern’ — including ‘inappropriate staff training’ — but accepted that protocols were being introduced to prevent such tragic accidents occurring again. But they weren’t.
The watchdog was guilty of ‘misplaced optimism’, the Ockenden report said. You will not find Cameron or Abbie mentioned by
name in the report. They are identified only as babies ‘X’ and ‘Y’, the way they were described in the original Healthcare Commission inquiry in 2007.
Had the Healthcare Commission not been guilty of ‘misplaced optimism’ after they were left brain damaged, it is possible Kate Stanton-Davies might still be alive. Her case epitomises the culture of negligence, whitewash and inhumanity at the core of this scandal.
Kate’s deteriorating condition following her birth at the midwifery-led unit in Ludlow in 2009 went unchecked by the midwife who had failed to put her in an incubator even when it was obvious one was urgently needed.
Kate became gravely ill. But it would be a further half an hour before the paramedics were called to the maternity unit. Kate was airlifted to Birmingham’s
Heartlands Hospital over 40 miles away. She died shortly after arriving at the hospital.
Kate’s life lasted barely six pitiful hours. But her parents, Rhiannon and Richard, had to wait three years to secure a jury inquest to find out why she died.
The hearing in 2012 confirmed what they had suspected all along: that Kate’s death was avoidable, attributable to serious failings in her care.
‘Had the midwife recognised her condition at birth and called 999 in time, Kate would also still be here,’ Rhiannon, now 45, said.
An internal audit, after Kate’s death, exposed wider systemic failings in the midwifery service, including midwives who altered notes retrospectively. Had these institutionalised failings been addressed immediately, it is possible that twins Ella and Lola Greene — stillborn in 2014 after staff failed to correctly read and interpret heart rates — might be alive today, along with Kye Hall (who died from brain injury and serious oxygen deprivation in 2015) and Pippa Griffiths (who died from a preventable infection in 2016). Finally, in 2017, due in no small part to the parents of Kate StantonDavies and Pippa Griffiths, the then Health Secretary,
Jeremy Hunt, ordered an independent investigation into the deaths.
Shrewsbury and Telford maintained that the rate of baby deaths at the Trust, which handled 4,700 deliveries a year, was no worse than elsewhere in the NHS.
This was the line which had been peddled to the bereaved for so long. It was also a lie.
Initially, the scale of the review by Donna Ockenden was limited to 23 families. However, dozens more cases were exposed by the Health Service Journal last year, so the inquiry was expanded.
Yet, even now, the culture of obstruction — and cover-up, many would say — persisted. For example, the Trust commissioned the Royal College of Obstetricians and Gynaecologists (RCOG) to also undertake a review, completed in 2017, which concluded that mortality rates were above average. But SATH delayed the publication of the report, only releasing it after paying the RCOG to produce another report that said all its recommendations had been implemented.
‘The RCOG regrets that the trust did not accept its initial report and waited six months to publish it alongside the addendum [addition],’ a spokesman for the Royal College said.
At the same time, stories in the Press about the scale of the tragedy were played down. In August, this newspaper published a report that more than 60 mothers and babies were feared to have died or suffered devastating harm — which was almost treble the number initially being investigated by the independent inquiry.
SATH labelled our coverage as scaremongering, which resulted in a letter from the Trust’s lawyers claiming our story contained ‘inaccuracies and misleading statements’. The letter concluded with a statement from Simon Wright, chief executive of SATH, who wanted to reassure women using the NHS maternity service that it is ‘a safe environment with dedicated caring staff’. He was not being ironic.
HEATHER Lort, the midwife on duty when Kate Stanton-Davies was born at the Ludlow maternity unit back in 2009, was finally struck off in 2018. A Nursing and Midwifery Council panel ruled that her misconduct was so serious that it led to the loss of a chance of survival for Kate, whose parents said she has ‘never said sorry’ for what happened.
Why was Lort, who also admitted serious failings in her care of another stillborn baby in 2013, allowed to continue working in the decade since Kate’s death?
It was because, an NHS spokesman said: ‘The initial investigations carried out in relation to Heather Lort fell far short of what the families concerned deserved.’
No one should be surprised in the light of what is still emerging about SATH, which now stands accused of holding on to the records of families who have come forward following the publicity about the shocking standard of care, something the authority denies.
The final report into Shrewsbury and Telford is not expected until 2020. One damning paragraph leaked suggests why. It reads: ‘The number of cases we are now being requested to review seem to represent a long-standing culture at this Trust that is toxic to improvement effort. It will take time, confidence, and considerable meaningful staff effort from “Ward to Board” to change this.’