Babies die – but no accountability

Thursday’s Board meeting of SaTH, our local hospital organisation, was downright bizarre. They closed most of the building where the meeting was held. Members of the public were greeted by security guards on our way in, and taken to a separate room to wait. Our bags were searched as we entered the building. Anyone visiting the toilet was carefully watched, with a security guard waiting outside. Three security guards sat around the sides of the room throughout the meeting. They were pleasant individuals and somewhat embarrassed – but it all felt closer to a high security prison than a public Board meeting. According to NHS England, the ‘purpose of NHS boards is to govern effectively, and in so doing build patient, public and stakeholder confidence that their health and healthcare is in safe hands’. Our Board’s approach to building confidence now seems to be to regard the public with hostility and suspicion.

There may be a reason for their fear. We believe they were trying to keep quiet about a series of avoidable deaths in local maternity services – and the truth about those deaths is now starting to emerge. In February, Secretary of State Jeremy Hunt ordered a review into a cluster of baby deaths in Shropshire. That review is now looking at the deaths of fifteen babies and three mothers. At least seven baby deaths between September 2014 and May 2016 have already been shown to be avoidable – they simply should not have happened.

SaTH, the hospital trust that runs our maternity services, seems to have been working hard to keep all this quiet: ducking FOI requests, withholding information from public Board meetings, and even failing to share information with Directors of Shropshire Clinical Commissioning Group, the organisation that pays for NHS maternity care. We only know what’s happening because of the brave parents who have fought for honesty and accountability from SaTH – and because of the excellent work in recent weeks of the BBC and the Mirror. When parents use the words ‘cover up’, they have a reason to do so.

When the BBC broke this terrible story earlier this month, the initial response from Medical Director Edwin Borman could be seen as a dismissive one. His comment was that the rate of baby deaths at the trust was no worse than anywhere else in the NHS. He seems to have missed the key point: that these deaths were avoidable. They should not have happened. Any avoidable death or injury should automatically lead to the most rigorous investigation and a meaningful commitment that it will not happen again. When the Medical Director seems to lack understanding of this, there is a problem.

The established tradition of secrecy and apparent cover up was maintained beautifully at Thursday’s Board meeting – although the reasons for refusing to discuss this tragedy slid about. We were initially told by Simon Wright, Chief Executive, that that the trust was committed to being candid and open, was a learning organisation, and wanted to make sure its services were even safer and better – but they couldn’t comment on what was happening in their maternity service as there was a risk of prejudicing the review, and women should speak to their midwife if they were worried.

Most members of the public present saw this as evasion, and the latest in a long history of evasions. We called on the Board to be accountable to the public it serves. We reminded Non-Executive Directors that their role is meant to be one of holding to account their Executive, the paid Senior Management team.  And we asked the Board as a whole to answer the questions that had been submitted to the meeting by bereaved parents. The response from the Chair of the meeting? He closed the meeting, and every single Board member went instead to a private meeting somewhere up the corridor. After the meeting was closed, and as they walked out of the room, we collectively told them ‘Disgraceful’ and ‘Shame on you’. We make no apology for that at all. The meeting was closed because of a refusal from the Board to be accountable, and because of a decision from the Chair to close the meeting in order to avoid that accountability. Media ‘tweets’ from the meeting make the sequence of events quite clear. It was not the public who closed the meeting – it was a Board that yet again refused to discuss this scandal in public.

And, rather oddly, after 30 or 40 minutes they all came back in again – with a new rationale for silence on avoidable baby deaths. They repeated that any public report or discussion might prejudice the outcome of the independent review. It’s not clear how, but they were very certain of it. If SaTH publishes the terms of reference for the review, this could clarify things, of course. There was a new reason. We were told that answering questions from bereaved patients would have breached confidentiality; a little strange, when the Board took the decision to withhold all information before they knew there were questions from parents; when the Board didn’t then take the trouble to find out which questions were being asked; and when parents, having battled for years, are desperate for information. And why on earth should parents who have lost a baby through avoidable death be less entitled to information than anyone else? SaTH’s logic here is an insult. And by the evening, the official account was that the meeting was ‘briefly adjourned following a period of disruption’. No – the meeting was halted by the Chair because of a pre-determined decision that the Board would refuse to report or answer questions on the avoidable deaths of babies in Shropshire, Telford and Wrekin. Disgraceful? Yes, without question.

There’s nothing to worry about though. We have been told (again) ‘The Board of The Shrewsbury and Telford Hospital NHS Trust is committed to openness and transparency’.

Members of the public shared our own thoughts and ideas while Board members were meeting in private.

• Most importantly, we pledged our absolute solidarity with the parents who are fighting for justice for their children.
• We talked about the scandalous deaths in Mid-Staffordshire a decade ago: how those deaths arose because of cost-cutting, and a Board that was so focused on cuts that patient care was pushed down the agenda, and frontline staff who were unable to raise issues around clinical safety because they would be ignored or more likely victimised. All of these strands now apply at our local hospital trust.
• We discussed the terrible pressures locally on midwives. SaTH managers recently assured campaigners that there is no difficulty at all recruiting midwives. The staff shortages and high workloads of midwives therefore reflect both a policy choice and inadequate funding. And of course over-stretched midwives will offer worse care. The routine (and dangerous) closure of midwife-led units to support an under-staffed Obstetric Unit is, likewise, a cost-driven choice by SaTH managers.
• We touched on the history: the warning from regulators in 2007 that maternity services were unsafe, but babies continued to die; the repeated warning (and improvement notice) in 2014 – but again babies continued to die.
• We talked about who is culpable for the terrible events in our maternity services. Babies have died for multiple reasons: different mistakes, by different staff, at different sites, over a long period of time. It makes little sense to blame individual midwives or doctors, because this is about systemic failure – the failure of the organisation and the people who lead it.
• When a maternity unit can lack a crucial Operational Policy in 2009 and STILL lack that policy in 2015, that’s a management failure. When essential training in neonatal resuscitation falls by the wayside, that’s a management failure. When staff shortages place women and babies at risk, that’s about senior managers putting budgets before patient safety. And above all, when avoidable deaths become normalised – that, more than anything else, is a dreadful consequence of senior managers who have forgotten what matters. We noted on Thursday how astonishing it is that the former Head of Midwifery, who presided over so many deaths, has been promoted within SaTH and now has a senior position with responsibility for patient safety.

Right at the end of Thursday’s Board meeting, many, many hours after the meeting began, we had the opportunity just for a few moments to tell the Board about some of this. We talked about the frighteningly close parallels with Mid-Staffs. We asked a question that parents still need to know the answer to: if SaTH had not refused a proper investigation of the avoidable death of Kate Stanton Davies in 2009, could other lives have been saved? We reminded them sharply of the systemic failures that have led to avoidable deaths. And we called for resignations. It is unacceptable that Cathy Smith, the former Head of Midwifery, has not been held to account. Simon Wright as Chief Executive has presided over an organisation that has not behaved with accountability or transparency. Edwin Borman as Medical Director has a clear responsibility at Board level for ensuring patient safety – and has failed. As a minimum, Simon Wright and Edwin Borman must go.

Board members listened but had no answers.

The NHS is wonderful, and saves lives, and belongs to all of us. For those reasons, mistakes that lead to catastrophic harm cannot be seen as ‘just one of those things’. A quiet review of individual cases by NHS Improvement will not dispel the anger and the bitterness of parents, and increasingly of a community that feels betrayed. It’s time for a public enquiry into a hospital trust that is failing in many, many respects. It’s also time for a change of leadership.