The Moral Obligation to Learn from Mistakes
On 24 June, the BBC reported that around 300 new cases would be added to an investigation that was already underway regarding avoidable baby deaths at Shrewsbury and Telford Hospital NHS Trust (SATH).
In 2017, Jeremy Hunt (then Health Secretary) had advised that an investigation into the deaths of babies who were either stillborn or died soon after birth at SATH would be carried out. The case numbers were at 23 at the time but slowly started to escalate and by November 2018 215 families had come forward. The issues raised in some of those cases involved failures to properly monitor foetal heart rates and delays in deliveries. Medical Negligence solicitors acting for some of the families suggested in a BBC article that they were "repeatedly seeing the same errors - failures in relation to heart trace monitoring and realising the baby is in distress, delays in taking women for an emergency caesarean and issues with the wrong use of forceps".
The Trust were under intense scrutiny at this time. In November 2017 it was placed in special measures and the Care Quality Commission was so concerned that the Trust had to submit weekly status reports. The investigation itself was marred by delays, including the investigation panel being pulled for fear they were ‘watering down’ the actions of the Trust and were not an independent panel of doctors and midwives.
NHS Improvement then requested that SATH set out the total number of stillbirths, neonatal deaths, and babies who had with brain damage since 1998 and a further 300 new cases emerged. Although not all are as a result of potentially sub-standard care it takes the total number of cases under review to over 500.
The Investigation is being headed by Donna Ockenden with the report unlikely to be due until the end of the year.
As medical negligence solicitors, we speak to many people who have been affected by similar issues at Trusts around the country. This will include babies who were stillborn or with brain injuries resulting in lifelong conditions such as cerebral palsy. Issues in maternity care are not limited to SATH but the sheer numbers of cases being investigated over the past decade at SATH are incredibly high which, if it transpires that large number are in fact due to poor care would be one of the worst failures in maternity care in the NHS.
Sadly, this review began because parents had insisted that the care being provided at SATH be reviewed because of their own experiences. Other parents then began stepping forward and it was only when NHS Improvement demanded the data that SATH released further information about other babies that may have been affected. The Duty of Candour has only really taken effect in the past 5 or so years. This requires organisations to tell patients what has happened and healthcare providers have a duty to act in an open and transparent way with people in relation to the care and treatment provided to them. It would therefore be disappointing if parents were not given completely transparent information about what happened to their babies. We sincerely hope that SATH will have learned from these tragic events and the report sheds some light for the bereaved parents.
If you have been affected by the issues discussed, please contact a member of our Medical Negligence team.
Punam Sood is a Senior Associate in the Clinical Negligence and Personal Injury Department. She has experience of a wide range of claims, including birth injury and acquired brain injury claims, claims relating to fatal accidents, those involving gynaecological injuries following childbirth and those due to the delayed diagnosis of cancer.
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