Another serious twist in the tale of the rapidly unfolding scandal into Shrewsbury and Telford NHS Trust maternity services was revealed this week (30 June 2020) as West Mercia Police announced they have launched a criminal investigation.
This comes on the heels of the revelation that the number of cases being examined has grown to around 1500, spanning a period going back as far as 1979, making it the largest review of its kind. Until now, the worse maternity-related health scandal was that of Morecombe Bay NHS Trust where 11 babies were found to have died as a result of poor care. This figure is dwarfed by the tragedy unfolding at the Shrewsbury and Telford NHS Trust where at least 42 babies and three mothers have died as result of negligence and a further 51 babies suffered brain damage.
Ockenden report leaked early
The sheer scale of the investigation may account for the time it has taken for the independent review panel overseen by NHS Improvement (NHSI) and led by senior midwife, Donna Ockenden, to report on its findings. Some of its initial findings were leaked to the press last year which made for depressing reading listing, as it did, some wearyingly familiar mistakes: inadequate heart monitoring, failure to spot group B strep, and insensitive responses to the trauma suffered by the families involved. We have seen these errors repeated time and time again when representing families whose babies have either been injured or who have died as a result of negligent care – but never in such numbers as the evidence to date at Shrewsbury suggests. Ms Ockenden noted that the leaked information appeared to be an internal status update and the complete review will be published towards the end of this year.
Trust repays money received for complying with maternity safety standards
The news also emerged earlier this year that the Trust will be repaying the almost £1m it received from the NHS Maternity Incentive Scheme in 2018. The scheme was originally set up by NHS Resolution, which manages the Clinical Negligence Scheme for NHS trusts, in response to the need to reduce the number of obstetric-related claims. As an aside, obstetric-related claims accounted for 10% of all claims received by NHS Resolution in 2018/19 but 50% in total value, which indicates the inherent seriousness of maternity-related errors. The idea behind the scheme was to reward those trusts that made significant steps towards improving the safety of their maternity services. In order to qualify for funds, trusts have to demonstrate that they comply with ten safety standards but compliance is judged by the trusts themselves – a case of marking their own exam papers. Ironically, or perhaps depressingly, after the Trust’s board self-certified its compliance with the scheme’s standards, the CQC rated the Trust’s maternity services ‘inadequate’ barely two months later.
Embedded poor practice difficult to shift
The overwhelming majority of maternity units around the country deliver babies safely under very difficult circumstances. However, as Morecombe Bay and Shrewsbury & Telford appear to indicate, there are some units where, once unsafe practices and uncaring attitudes take hold, it is very difficult to shift the culture. This is the third blog in which I have written about failings of Shrewsbury’s maternity services and the scale of the failure is not only alarming but, given the intervention of West Mercia Police, quite possibly criminal. All trusts are struggling with staffing and funding issues but that can never be an excuse for any maternity unit to act with indifference to the very people they are supposed to be helping.
I am advising a number of families, affected by the poor care they received at Shrewsbury & Telford NHS Trust, on potential medical negligence claims. If you have any concerns about the standard of maternity care you have received, I would be happy to chat through the options open to you.