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Shrewsbury and Telford Hospitals (SaTH) NHS Trust has been under investigation since 2017. Initially, the scope of the investigation was to examine 23 cases, but the Shrewsbury and Telford maternity services investigation has subsequently uncovered 1,862 serious incidents, including hundreds of avoidable deaths and an unusually high number of maternity deaths between 2000 and 2019.
Despite the investigation being launched in 2017, the report seems to reveal that regulators had been aware of problems since 2007, yet nothing appears to have been done to improve services.
Today, an interim report into the biggest maternity scandal in the history of the NHS has called for urgent and sweeping changes in all English hospitals to prevent more avoidable baby deaths, stillbirths and neonatal brain damage.
The report includes a series of immediate actions and “must do” recommendations for all hospital trusts to improve maternity safety “at pace”. These include formal risk assessment at every antenatal contact, twice-daily consultant-led maternity ward rounds, women and family advocates on the board of every NHS trust, and the appointment of dedicated lead midwives and obstetricians.
The report refers to a “toxic culture” and substandard care, including failures to recognise when there were problems with births.
There was also evidence of mothers frequently being treated unkindly by staff with their concerns simply dismissed. In other cases, there appeared to have been “little or no discussion and limited evidence of joint decision-making and informed consent…”
It also found that the trust had caesarean section rates that were consistently 8-12% below the average for England and that there did not seem to be a consideration of whether the apparent culture of keeping rates low contributed to unnecessary harm.
In addition, there was clear evidence that midwives failed to raise the alarm when there were problems and when they did doctors did not act on them properly.
Other problems included failures to properly monitor babies’ heart rates during labour.
Perhaps most concerning is that after incidents the trust failed to fully investigate and so there has been an underlying failure to learn lessons. The review found that, for example, there were various reports and recommended improvements that had not been implemented by the Trust because of “inconsistent processes…with evidence that when cases were reviewed the process was sometimes cursory. In some serious incident reports the findings and conclusions failed to identify the underlying failures in maternity care.”
SaTH has been given 27 actions to improve safety, including risk assessment for mothers at every antenatal appointment, better information and choices, improvements in monitoring and instructions regarding the care and use of Oxytocin; and have been told to improve its investigation of incidents.
This is sadly not the only trust of which concerns about the quality of maternity care have been raised. In 2016, the National Maternity Review reported widespread problems with quality and safety, a failure to learn from mistakes, underreporting of safety incidents and missed opportunities to prevent stillbirths even when the mother had expressed concerns.
As I wrote in my blog article earlier this year, there needs to be an open and honest culture in the NHS, with everyone from senior managers to frontline staff learning from mistakes, so that other families do not have to suffer the same devastating experiences.
What is coming out loud and clear from the investigation into Shrewsbury and Telford maternity services is that when unsafe practices take root and no positive remedial action is taken, it can be very difficult to shift the culture and turn things around. This must not be allowed to continue.
More must be done to learn from these reviews and investigations and implement safe maternal care in which mothers are supported and, most importantly, listened to. The recommendations must be swiftly and effectively implemented and there must never be a compromise on patient safety.
Donna Ockenden succinctly concludes:
“We owe it to the 1,862 families who are contributing to this review to bring about rapid, positive and sustainable change across the maternity service at The Shrewsbury and Telford Hospital NHS Trust. Implementation of the recommendations from this first report and the final report of 2021 will be their legacy.”
If you have concerns about the treatment you and your baby have received at Shrewsbury and Telford NHS Trust or any other healthcare setting, Novum Law’s team of specialist medical negligence solicitors can help on a ‘no win, no fee’ basis.
To find out more information, contact us on Freephone: 0800 884 0777 or email: firstname.lastname@example.org.