Wednesday, 20 November 2019

Shrewsbury and Telford Maternity Services

The Independent has obtained a leaked report into maternity services at the Shrewsbury and Telford Hospital Trust which is described, in the headline to the story as uncovering the "Largest maternity scandal in NHS history".

The story is written by Shaun Lintern, the Independent journalist, formerly of the Health Service Journal, who has had a long involvement with families affected by what they regarded as inadequate maternity services at the Trust. The Stanton-Davies family, who lost their baby daughter, Kate, at the Trust's Ludlow unit in March 2009 had to fight for a proper investigation and Inquest, which ultimately revealed serious failings as well as evidence of retrospective alteration of medical records.

Shaun Lintern reveals:

"The leaked report identifies:

A long-term lack of informed consent for mothers choosing to deliver their babies in midwifery-led units – where risks can be higher if problems occur – which “continues to the present day”

A long-term lack of transparency, honesty and communication with families when things go wrong. This supported a culture that was “disrespectful” to families who had been “damaged” as a result

Failure to recognise serious incidents. Many families who had undergone horrific experiences were told they were the only ones and lessons would be learnt. The report said: “It is clear this is not correct”

A long-term failure to involve families in investigations that were often poor and described as “extremely brief” and “overly defensive of staff”

A lack of kindness and respect to parents and families with multiple examples of deceased babies given the wrong names in writing or referred to as “it”

Not sharing learning, meaning “repeated mistakes that are often similar from case to case”. Failure to learn was present from the earliest case of a neonatal death in 1979 to cases occurring at the end of 2017

A lack of support for families who have “experienced significant loss and tragedy"

A long-standing culture at the trust “that is toxic to improvement effort”

Those of us who practise in clinical negligence litigation are all too well aware that obstetric cases account for about 50% of the compensation payments made to claimants by NHS. It should be a common goal not only to provide justice in those cases where harm has already occurred, but to reduce the number of cases of avoidable harm in the future. Everyone can make mistakes, but individuals and institutions should learn from mistakes to prevent them being repeated.

In the final section of my book, Clinical Negligence Made Clear, I wrote this:

"Whoever fed professionals the line that [healthcare professionals]  should admit nothing when something goes wrong, has a lot to answer for. Openness and good communication with patients and their families is much more likely to bring down the number of claims rather than increase it. And candour can help reduce patient harm. If professionals become more open to admitting mistakes, and investigating them thoroughly, then they will become more open to changing practice and improving the systems within which they work. To bring this about healthcare professionals and other staff need to be supported, so that when things do go wrong they can admit mistakes and point out the errors of others and of the system without fear that it will count against them. When healthcare professionals raise concerns they are called “whistleblowers”. This term implies that the act of raising concerns is exceptional and that most colleagues keep quiet even when they know something is going wrong. Surely, the process of raising concerns should be commonplace – however else will improvements be made if the clinicians treating patients and working within the system are not supported to point out deficiencies and suggest positive changes? 

"So both patients and their families, and professionals and staff need to be supported. This support needs to be in place at a very early stage for it to have benefits."

Complainants should not be viewed as irritants. Practitioners should be supported, and managers and policy-makers need to develop a culture of candour and openness to positive change. That is not a new message - Sir Robert Francis said it in the Mid-Staffs report in 2013. The message will have been embraced by many within the NHS, but this leaked report suggests that for too many it is a message that has not been heard.