An Unfolding Tragedy

Resign – and Suspend

How many more babies have to die in Shropshire’s maternity service? How many more have to be left with lifelong disabilities as a result of hospital mistakes? We have been told again and again by hospital chiefs that ‘lessons have been learned’ – and each time, more babies have died.

There is a catastrophic failure of leadership in our local hospitals, the Royal Shrewsbury and Telford’s Princess Royal (‘SaTH’).

If Chief Executive Simon Wright cannot guarantee safe patient care, he should resign.

As Medical Director, Dr Edwin Borman is directly responsible for the quality and safety of patient care. There is now an investigation into the deaths of babies in Shropshire’s maternity service, ordered by Health Secretary Jeremy Hunt. Dr Borman should be suspended until that investigation has completed.

When Medical Director Edwin Dr Borman responds to reports of avoidable baby deaths by saying ‘When I look at the perinatal mortality rate at our trust compared to the rest of the NHS, we are at an equivalent level to the rest of the country,’ he shows that he is not fit to do his job. The coroner and the courts have found that babies in Shropshire have died avoidable deaths. Every one of those deaths is both a tragedy and a disgrace. Hiding behind averages, when babies have died unnecessarily, is as unacceptable as it gets.

The heart breaking tragedy of avoidable baby deaths

On Wednesday last week, the BBC broke the news. Most of us know about the tragic death of Kate Stanton Davies in 2009 – and the desperate attempts of SaTH, the hospital trust, to evade taking responsibility for her death.

We now know of many more deaths of babies. Jenson Barnett, June 2013. Twins Ella and Lola Greene, September 2014. Sophiya Hotchkiss, September 2014. Oliver Smale, March 2015. Jack Burn, March 2015. Kye Hall, August 2015. Graham Scott Holmes-Smith, December 2015. Ivy Morris, December 2015. Pippa Griffiths, May 2016. All but two of these deaths have been ruled as ‘avoidable’ by the coroner or the courts. The remaining two are regarded as ‘suspicious’.

These are the babies we know about. Eleven small lives lost as they barely began. It is very likely that other babies will have died unnecessarily. It is a virtual certainty that other babies will have been left brain damaged and facing a life time of disability. It is possible that mothers have also died unnecessarily. We don’t know, because SaTH – the hospital trust – is mired in a culture of secrecy. This is a story that is just beginning to unfold.

This is a scandal on a par with that of Mid-Staffordshire, when senior managers were so fixated on targets and cuts that patients died in large numbers; the worst scandal in the history of the NHS. In Shropshire, we have a comparable tragedy now emerging.

Was there a cover up? We believe there was

It is worth remembering the seven year fight endured by the parents of Kate Stanton Davies to get justice for their daughter. The Health Ombudsman criticised not just the failures in Kate’s care, but also the ‘maladministration’ in SaTH’s handling of the complaint from her parents.

There is evidence that the culture of cover up continues.

Three things stand out:

  1. On 4th April 2016, just over a year ago, SaTH held a special Board meeting to discuss the death of Kate Stanton Davies. A member of the public asked if there had been any other avoidable baby deaths since Kate’s death, and – if so – how many. The then Director of Nursing and Quality picked up the question. Astonishingly, she seemed not to know. She replied that she couldn’t quite remember, but she thought ‘one or two’. At least seven avoidable deaths of babies had taken place at that point in time. Why did she not know? And can it really be the case that the Chief Executive and the Medical Director and the Chief Operating Officer and the Clinical Governance Manager – all of them present in the meeting – were also unaware of what was happening in their organisation? And if they did know, why did they not speak out?

    We believe it is unlikely that none of the senior managers present at that meeting knew of the catalogue of unnecessary deaths of babies in SaTH’s maternity service. This was a meeting about the death of one baby. Board members were in tears, and pledges were made about lessons learned. And incorrect information on the deaths of other babies was given at that meeting: to the Board, the public, and to the parents of Kate Stanton Davies. This is outrageous.

  2. There has, quite rightly, been a major campaign against the closure or downgrading on cost grounds of our rural maternity units in Oswestry, Bridgnorth and Ludlow. On 19th January this year, the Coordinator of one of those campaigns submitted a Freedom of Information request to SaTH. She asked for information about baby deaths, maternal deaths, and ‘adverse events’ in maternity care, broken down by year and site. SaTH refused to answer, failing to comply with its legal obligations under the Freedom of Information Act.

    Why, and who took the decision not to answer? We know from an email dialogue with Chief Executive Simon Wright that he was involved. The refusal to answer the request on baby deaths could have been part of the overall culture of secrecy that is so pervasive in this organisation. It may be worse; it may have been a deliberate and conscious decision to withhold information that they wished to keep well away from public view.

  3. And finally, Jeremy Hunt’s instruction for an investigation into these cases was given in February this year. And at SaTH’s public Board meeting on 30th March, there was not a mention of this. What could be more important than an investigation into avoidable baby deaths? The priority for the Board seems to have been keeping this out of the public eye. The lack of honesty and accountability are nothing short of breath taking.

An organisation in free fall

A single avoidable death is a tragedy, a ‘never event’. The number of deaths of babies that has taken place is almost unimaginable – but this has happened. This is a series of tragedies, of lives lost unnecessarily, and of parents left grieving for the child they never had the chance to know. The shock and the hurt of this will be felt by all of us.

We know that for many of these babies, there were multiple failings in their care. Their deaths occurred over time, in different parts of the maternity service, and for different reasons. This cannot be explained by mistakes made by individual staff members. This is systemic failure. We know about staff shortages, and gaps in training, and parts of the maternity service left without operational policies for year after year. Again, this is about systemic failure. This is an organisation that is going disastrously wrong – and the people responsible for that are the people at the top.

That’s why an internal review conducted by regulators cannot be enough. We fully support the calls from the parents of Kate Stanton Davies for a public enquiry. Honesty and accountability have to be part and parcel of our NHS.

The investigation has to be wider than the dreadful failures of care in the maternity service. We believe that SaTH is now a dangerous and failing organisation. Any review has to be broadened to look at the other SaTH services that are falling apart. Neurology is closed to new patients for six months; ophthalmology closed for six months; spinal surgery closed; dermatology in chaos; A&E performance amongst the worst in the country.

We know from staff about the entirely unacceptable pressures that they work under. We know of nurses struggling to even take a toilet break during their shift, never mind a meal or rest break. We know of the staff survey results that reveal SaTH to be a rotten place to work for so many staff. Very importantly, we know of staff who are scared to speak out about poor standards of care or services that are going wrong. They believe that they will be disciplined or will lose their jobs if they tell the truth. Something is going badly wrong.

And while core services fall apart and patients are put at risk, the senior managers of SaTH pretend everything’s fine. They focus on driving through cuts, achieving their ‘control totals’ – and keeping secret any awkward events that don’t match up with the pretence.

We deserve better. We need good quality care – and when things go wrong, we need to be treated with honesty and respect.

It’s a bigger crisis

The NHS is in deep trouble, nationally and locally. In the UK, we spend far less on healthcare than comparable countries. Our NHS is being starved of essential funds. That’s why A&E departments across England were in crisis this winter. It’s why ambulance trusts are missing their targets for emergency response times. It’s why NHS England has quietly abandoned the ’18 week referral to treatment’ guarantee for NHS patients – a horrific move, one that ushers in widespread rationing of routine treatments including hip and knee replacement surgery.

Locally, things are even worse. Shropshire and Telford and Wrekin have above average health needs – but we’re the sixth worst funded area in the country. We’ve asked our MPs to take forward a fight on this, but four out of five have not got around to replying. Our ‘Sustainability and Transformation Plan’ is about cutting £135 million a year from local healthcare spending. Our community hospitals face bed cuts and the loss of our Minor Injuries Units. The rural maternity units in Oswestry, Bridgnorth and Ludlow are seen as too expensive – and face closure or downgrading.

And when the focus is on driving through service cuts and meeting financial targets, that’s when senior managers can start to lose sight of their priorities. It’s inexcusable – but it’s important to understand it. Yes, things are going catastrophically wrong at our hospitals in Shrewsbury and Telford – but there’s a bigger picture sitting behind that. Shropshire needs fair shares when it comes to NHS and social care funding. We need the NHS in the UK to get the same funding as healthcare systems in comparable countries. We need a government that invests in an NHS workforce for the future.

The scandal of babies dying shows what can happen when organisations lose their way. Without more funding for the NHS in Shropshire and Telford and Wrekin, it is inevitable that many more of us face substandard healthcare. There has never been a more important time to fight for our NHS.

Going forward, we will be giving our full support to the parents fighting for justice. For now, could you send an email to Peter Latchford, Chair of the Board at SaTH, the hospital trust? Ask him to end the culture of secrecy, and take forward the suspension of Medical Director, Dr Edwin Borman.

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