A Tragedy in Maternity Care: Who knew? Why did they keep quiet?
Shropshire, Telford and Wrekin Defend Our NHS spoke this morning to Richard Stanton, father of
Kate Stanton Davies. Kate was born in March 2009. She died when she was just six hours old, and
her death was avoidable.
View Press Release
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An example in passing of SaTH’s failure to understand the gravity of its situation. Adam Gornall gave a remarkable interview to the Shropshire Star in February 2016. This was in response to the publication of the MBRRACE ‘red’ rating for 2013. Adam commented on the thorough assessment of each case, and that no ‘thematic reason’ or ‘common thread’ had been found. On stillbirths, he said ‘In 2012, the stillbirth rate was similar to the national average and in 2014 and 2015 it was lower than the expected national average’.
The Clinical Director was out of touch. In 2014 and 2015, the stillbirth rate was above the average for the MBRRACE comparator group (i.e. for similar organisations). Adam, like the CQC, will not have had access to the MBRRACE reports and their stabilised and adjusted figures at the time he gave that interview, but he might reasonably have been expected to have a broad feel for how SaTH compared with comparable trusts.
In the same interview, there is also a genuinely surprising omission around neonatal mortality. Again, the MBRRACE stabilised and adjusted figures were unavailable – but Adam as Clinical Director of maternity should surely have had an overview of the crude neonatal mortality rate in the service he led. Adam gave the Shropshire Star the impression that 2013 was an anomaly; that SaTH’s maternity service was steadily getting safer. In reality, in both 2014 and 2015, the crude neonatal mortality rate at SaTH was above that for 2013.
Adam either did not know if the number of babies dying in SaTH’s care was going up or down, or he chose to withhold the information on neonatal mortality in favour of reassuring the local paper that everything was fine. We do not believe that either of these would be acceptable.
SaTH is not well-led. SaTH is not a learning organisation.
The CQC’s work in 2014/ 2015 was not fit for purpose. We welcome the closer scrutiny of maternity that has taken place subsequently. We would also welcome some robust questions being asked about why, in 2014/15, the CQC completely failed to describe a service in crisis.
On our local CCGs, and on the role of NHS England – whatever that may have been – it is clear that transparency has been almost totally absent.
We do not know at this stage what the eventual conclusions of the Ockenden review will be. From leaked information, it is reasonably clear that what has happened at SaTH can best be described as a scandal. We think it is likely that this is the worst maternity scandal in the history of the NHS. Women and babies have been terribly let down by SaTH. They have also been let down by the wider NHS system that failed to protect them: by our local CCGs, by the CQC, and by NHS England.
The NHS is doing a disservice to those who have died or been harmed if it does not now take forward two separate strands of work. The first is of course to ensure a safe maternity service for the people of Shropshire, Telford and Wrekin. The second is to stop comparable tragedies happening to other people in other areas. That second strand requires ending the secrecy that is endemic in the NHS, and overhauling the regulatory systems that are now conspicuously failing.
Gill George, Chair
Julia Evans, Secretary
Shropshire, Telford and Wrekin Defend Our NHS
5th August 2020
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The following letter has been sent to all our local MPs. We are calling on them to ask the Secretary of State to halt Future Fit. He can do that under the 2012 Health & Social Care Act because the decision has been referred to him by Telford & Wrekin Council. The Secretary of State has asked his Independent Reconfiguration Panel [IRP] to make recommendations, but the final decision is his. We made our own 124-page submission to the IRP which was accepted to be included in the Panel’s deliberations. You can download it from here.
On the 18th February, Telford and Wrekin Councillors voted unanimously to refer the decision on Future Fit to Matt Hancock, Secretary of State for Health and Social Care. That referral is now with the Independent Reconfiguration Panel.
The reality is that Future Fit will lead to worse healthcare not just for the people of Telford and Wrekin, but for Shropshire and Powys people too. It is also clear that Future Fit cannot solve the financial crisis in our local NHS, but will exacerbate it.
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Behind the brave talk from health bosses, the Future Fit cuts and closure plans are in desperate trouble.
Tonight, Telford and Wrekin Councillors voted unanimously to refer the Future Fit decision to the Secretary of State for Health.
This, set alongside a continued public campaign against Future Fit, creates a very real prospect the defeat of these disgraceful plans.
Councillor Andy Burford, Chair of the Health Overview and Scrutiny Committee and Joint Chair of the Joint HOSC with Shropshire Council, introduced the motion for referral. It was a calm, measured and well-informed speech – impressive in its careful demolition of the case for Future Fit.
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On Monday, February 18, Telford and Wrekin Council will be holding an Extraordinary Meeting to discuss referring the decision to proceed with Future Fit to the Secretary of State for Health and Social Care. This is a procedure laid down in the Health and Social Care Act of 2012 when a local authority believes that a decision by the health bosses is not in the best interests of local people. It will halt progress on Future Fit until the Secretary of State has ruled on the proposals and may result in the health bosses being told to look again.
In advance of the Meeting, Shropshire, Telford and Wrekin Defend Our NHS has written to each individual Councillor to urge them to support the referral, but to do so on the basis that we need both our A&Es. The letter is below.
Dear Councillor
We are writing to you in advance of the Extraordinary Council Meeting on Monday 18th February.
Firstly, and most importantly, we share your strong concerns over the outcome of the CCG Joint Committee meeting of 29th January. The meeting itself was in many respects shoddy, as was the consultation that preceded it. The decision will leave us with a hospital that is too small to meet demand, and with increased journeys to care that will cost lives. There is no question that the outcome is detrimental to healthcare for Telford and Wrekin people (as it is for Shropshire and Powys people). Continue reading
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A meeting dominated by the A&E closure decision
When the SaTH Board met on Thursday 25th October, they were joined by around 40 campaigners, strongly opposed to the overnight closure of the A&E at Princess Royal Hospital.
The SaTH pretence on Thursday was that no decision had been taken on overnight A&E closure. Really? One brief exchange gave the game away:
One Board member said, “What happens when it closes?”.
“IF“, barked the Chair.
“Yes, what happens IF it closes”, said the Board member.
Despite the games playing, the Board was on the back foot for much of the meeting. Sharp challenges from campaigners forced them to tear up the planned agenda. The Chair started off by announcing that public questions on A&E closure would be taken at the end of the meeting – many hours away. There were shouts of “shameful”, and he was told he was treating the public with contempt.
He eventually backed down. The meeting was dominated by a public session on A&E closure that ran for about an hour. And these were not deferential ‘public questions’. These were sharp, well-informed – and angry – challenges to plans that put lives at risk.
Again and again, Board members looked anxious. They simply had no convincing answers. Yes, they still intend to push this massive attack through. But they were on the defensive, again and again and again.
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Just over £5 million according to hospital trust SaTH. That’s £3.4 million in lost ‘business’, as local patients get packed off to out-of-county hospitals. And another £1.7 million for the extra ambulances to take them there, according to Shropshire CCG last week. That’s OUR money, by the way.
This is absurd. SaTH needs only five middle-grade doctors to keep BOTH A&Es open overnight. If they’ve really got £5 million to throw around, how about spending it on getting those staff in place instead of overnight closure of the A&E at Princess Royal?
The reality of course is that SaTH wants to run down the A&E. It’s the first step in implementing Future Fit, with its massive cuts and closures – and we can expect this to be followed quickly by further service changes at both hospitals. For SaTH’s senior management team, it’s about ‘investing’ £5 million to balance the books more easily over the next few years. The current decision on part-closure of Princess Royal’s A&E was taken by SaTH in July, disclosed to the BBC by a SaTH Consultant, and confirmed by another SaTH doctor. SaTH didn’t come clean, because if they had, people might have concluded that the Future Fit consultation was a con trick. Continue reading
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This letter was handed to Matt Hancock, the current Secretary of State for Health at the Conservative Party Conference in Birmingham by a number of supporters of Shropshire, Telford & Wrekin Defend Our NHS. It contains specific proposals that would ensure there was no need to close either A&E.
2nd October 2018
Matt Hancock MP
Secretary of State for Health
Dear Mr Hancock
As residents of Shropshire, Telford and Wrekin, we are asking for your help.
You will know about the massive crisis in our local hospital trust, ‘SaTH’. The trust runs two A&Es and hospitals, at Shrewsbury and Telford. You are of course aware of the independent review of avoidable deaths and occurrences of harm in maternity. Our experience is that there is a continuing culture of denial at Board level. How is it possible to learn from mistakes if they are not acknowledged in the first place?
We assume, too, that you will know of the CQC inspection that has just finished. The leaked CQC letter has been widely reported, and it identified serious risks to patient safety. It cannot be acceptable ever in the NHS for a diabetic patient to be left without food or fluid for 15 hours, for a high dependency area to be left completely unstaffed for 15 minutes, or for a patient with signs of deteriorating sepsis to be left on a trolley in the corridor without adequate care. There is a desperate shortage of staff and beds at both hospitals, and current reconfiguration plans will make this much worse.
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That’s the only possible view of the leadership of Shrewsbury and Telford Hospitals Trust following the farce of a Board meeting yesterday.
In the midst of overwhelming crisis, the Board had a brilliant plan: ‘Let’s ignore it’. The periodic injections of reality came from the many members of the public present, and from the one honourable Non-Executive Director who did a decent and principled job of challenging the positive spin.
The horrors of unsafe care exposed by hospital inspectors were touched on (momentarily) by Chief Executive Simon Wright. The Trust “will work closely with the CQC and ensure that we can evidence the learning and evidence those things where there may have been confusion”. Not a mention there of staff telling inspectors of unsafe and degrading care; of patients treated like ‘animals’ and ‘cattle’; of inspectors repeatedly going to the aid of patients because there weren’t enough staff. Members of the public expressed horror that staff have to speak to hospital inspectors about unsafe care because they don’t trust internal reporting mechanisms. There’s no evidence the Trust Board is too bothered about this.
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In Shropshire, Telford and Wrekin Defend Our NHS, we welcome today’s intervention of the Care Quality Commission (CQC), and the issuing of an enforcement notice. The observations of hospital inspectors – leaked and widely publicised last week – were genuinely shocking.
It is wholly unacceptable that patients in our hospitals have been ‘boarded’ in inappropriate areas, because of a lack of beds – on corridors, in areas without access to call bells or oxygen, or on wards so crowded with extra beds that a resuscitation trolley could not be pushed through.
It is disgusting that hospital inspectors had to go to the aid of patients multiple times because of staff shortages. It is close to unbelievable that those patients included a diabetic patient left without food or fluid for 15 hours; close to unbelievable, too, that a high dependency area was left completely unstaffed for 15 minutes.
We applaud the courage of staff who approached hospital inspectors, and told them of the problems. It was staff who blew the whistle here. A letter from the CQC to hospital trust SaTH reported: “Staff across all areas and grades raised concerns with us about this practice (‘boarding’) and told us they felt it was unsafe, demeaning, undignified, and disgusting. Two staff members told us they felt patients who were boarded were treated like ‘animals’ and ‘cattle’.”
Something has gone very badly wrong at our local hospitals. Julia Evans is Secretary of Shropshire, Telford and Wrekin Defend Our NHS, and is a former A&E Nurse at the Royal Shrewsbury Hospital. She says, “NHS cuts lead to shockingly bad care – and that is the fundamental lesson that must now be learned from the crisis at Princess Royal and the Royal Shrewsbury Hospitals”.
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