What’s the worst thing about Thursday’s Ockenden Review into the latest NHS maternity scandal, at Shrewsbury and Telford Hospital? Is it the scale of the trauma, the deaths and the lack of compassion which put together make for the worst maternity scandal that the health service has ever seen? The inquiry started with 250 cases, but widened that to a horrifying 1,862 cases where care may have been inadequate. These are just the interim findings as the investigation continues and will publish a final report in 2021.
Perhaps it’s the details that are the worst thing about the document. The review found 13 maternal deaths in 18 years, stillbirths which could have been avoided and deaths of babies due to repeated attempts at forceps deliveries and a refusal to perform caesarean sections which then led to severe trauma for the baby or the baby’s death. On those last incidents, the report observes that women were made well aware that their requests for a C-section were being refused because the Trust wanted to keep its rates of these operations as low as possible:
‘The review team observed that women who accessed the Trust’s maternity service appeared to have little or no freedom to express a preference for Caesarean section or exercise any choice on their mode of delivery.’
The individual stories are still more harrowing. Women were blamed for their babies’ deaths, told the agony they were in was ‘nothing’ and midwives failed to monitor mothers in the birth centre because ‘the unit was busy’. This is what happened in that last case:
‘When problems were eventually identified in labour there was a delay in transferring the mother to the labour ward, where her baby was delivered in very poor condition and hypoxic ischaemic encephalopathy was later confirmed. The baby subsequently died. The family were critical of the ensuing investigation and correspondence with the Trust, and said during a meeting with the Review Chair that they had been “put off, fobbed off and had obstacles put in our way”.’
Or perhaps it’s the fact that the Care Quality Commission had rated this Trust as ‘good’ in 2015, suggesting that a system of oversight that was supposed to have been beefed up following previous scandals still missed problems.
Yes, there were previous scandals. Ones that were supposed to have changed the way maternity services were provided in this country – and perhaps more importantly change the way mistakes were dealt with. Morecambe Bay was – until this week – known as the worst maternity scandal to hit the NHS. The review into that disaster, which involved one maternal death and 11 avoidable deaths of babies between 2004 and 2013, concluded:
‘Today, the name of Morecambe Bay has been added to a roll of dishonoured NHS names that stretches from Ely Hospital to Mid Staffordshire. This Report sets out why that is and how it could have been avoided. It is vital that the lessons, now plain to see, are learnt and acted upon, not least by other Trusts, which must not believe that “it could not happen here”. If those lessons are not acted upon, we are destined sooner or later to add again to the roll of names.’
The report’s author, Dr Bill Kirkup, could not have anticipated the scale of the scandal that would follow Morecambe on that roll. This week’s review makes similar calls for what happened to never be repeated elsewhere, saying:
‘Having listened to families we state that there must be an end to investigations, reviews and reports that do not lead to lasting meaningful change. This is our call to action. We expect to see real change and improved safety in maternity services as a result of findings from these 250 case reviews and our resultant Local Actions for Learning and Immediate and Essential Actions whilst we continue to work towards completion of the full and final report.’
Will this be the last report on a maternity scandal in the NHS? Or just the latest?
But there’s something even worse than that. It is something Kirkup identified in Morecambe that was repeated once again in Shrewsbury and Telford. These reviews only came about because bereaved parents launched their own investigations into the deaths of their children and had to fight and fight and fight to be taken seriously by a system which had showed them no compassion in the darkest time imaginable.
James Titcombe wrote 400 letters as he tried to get justice for his son Joshua, who died after a catalogue of failings by staff at Furness General Hospital in 2008. He was frequently fobbed off by organisations across the health service who treated him as though he had merely been driven mad by grief, rather than someone who had spotted unacceptably inadequate care of mothers and babies. In Shrewsbury and Telford, it was Rhiannon Davies and Richard Stanton, who lost their daughter Kate six hours after she was born, and Kayleigh and Colin Griffiths, who lost their daughter Pippa at one day old. The two families had to mount their own investigations into what was going on at the maternity unit, eventually forcing an independent inquiry into the trust. It has taken them a decade to get justice.
Why should our system wait for parents in unimaginable pain to force these reviews? Why is it the case that so often their valid concerns are dismissed, their observations of toxic cultures considered merely part of their own grieving process? Worse, when those parents get some form of justice for their babies and the others who suffered in the same hospital, they are then forced to see the very mistakes they must grieve being repeated elsewhere.
The beauty of the NHS is that it treats every patient the same – or at least that is its founding principle. And yet this report reminds us that not everyone is treated with the same level of seriousness. The Shrewsbury and Telford families did not get that treatment and have had to fight to stop others being dismissed in the future. The very worst thing would be if they had to see the same thing happen to other families again.
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