When something goes wrong in the NHS, there’s a need for healthcare providers to say ‘What happened, and how can we make sure it never happens again?’
Our hospital trust, SaTH, doesn’t work like that. When they fail, the response seems to be a defensive one, a knee jerk response of ‘Well, nothing happened, and even it did, it wasn’t our fault’. It’s dangerous, because it prevents learning, and it places lives at risk.
WE BELIEVE THAT HOSPITAL TRUST LEADERS ARE NOW GAMBLING WITH THE LIVES OF MOTHERS AND BABIES THROUGH CUTS TO MATERNITY CARE. WE ALSO BELIEVE THAT THEY ARE TREATING BEREAVED PARENTS – PARENTS WHO HAVE LOST THEIR BABIES THROUGH DEATHS THAT COULD AND SHOULD HAVE BEEN AVOIDED – WITH GENUINELY SHOCKING CONTEMPT.
WHAT ARE YOU DOING AT 3.30 PM ON TUESDAY AFTERNOON? COME ALONG TO THE PEACEFUL PROTEST AT THE SHROPSHIRE EDUCATION AND CONFERENCE CENTRE AT ROYAL SHREWSBURY HOSPITAL. PLEASE COME TO THIS IMPORTANT EVENT. BRING YOUR BABIES AND KIDS IF YOU LIKE. BRING A BANNER OR A PLACARD IF YOU HAVE ONE. MORE DETAILS ARE AT THE END OF THIS POST.
There are two strands of horror story to unpick here.
Tragedies That Have Happened
There have been nine avoidable baby deaths in SaTH’s Maternity Service, according to the BBC. An important national report has just found SaTH to have rates of stillbirth and neonatal deaths that are 10% higher than they should be. There is a current NHS Improvement investigation into at least 23 cases of baby deaths or avoidable harm. This is not a service that is doing well.
SaTH has also carried out its own review, due to report to selected ‘stakeholders’ on Tuesday afternoon. The review covers the safety of maternity care over the ten year period when so many deaths have occurred; whether or not lessons have been learned; and whether or not there is a need for further learning.
With grotesque insensitivity, SaTH has decided that the parents of the babies who died in SaTH’s care are not stakeholders, and are not allowed to be at the meeting. There are at least three parents who want to attend the meeting, who want the opportunity to talk to other stakeholders about their experiences, and their views of SaTH’s ability to learn lessons from catastrophic mistakes. Their stories are harrowing, and they have questions that SaTH has failed to answer. It may be convenient for SaTH to exclude those bereaved parents – but it is completely unacceptable. Whatever else SaTH has learned, they plainly haven’t got to grips at all with working in equality with and showing respect for people who have suffered incalculable loss.
A Tragedy Waiting to Happen
We believe SaTH’s maternity service is in real trouble. This is absolutely not the fault of midwives – but they’re working in a service that is under-staffed, under-resourced, and that increasingly lacks the capacity to provide consistent high quality care for local women.
We’ve heard about mothers waiting far too long for an induced birth because Telford’s Delivery Ward is full – in one recent case, a wait of two days. A delayed induction, for precisely the same reason, led to a local baby dying back in 2013. This is just not safe. We are hearing now of midwives working under terrible pressure in Shrewsbury and particularly in Telford – and of new mothers feeling ‘pushed out’ of the Obstetric Unit because of the pressure on beds.
We’re hearing from Ludlow women now having to travel to Shrewsbury for antenatal care; of Oswestry women expected to travel to Telford for postnatal care a day or two days after giving birth; of women being refused home births because there aren’t enough midwives to care for them. We noticed – and SaTH presumably hoped we wouldn’t – the online promise that Ludlow and Oswestry would provide local midwife care when the Units were closed to women giving birth – and we also noticed when SaTH deleted that promise from its website, and took away consistent care.
Running a service on this shoddy basis isn’t fair to mothers – and it isn’t fair either to the midwives who are desperately trying to hold the service together. It is simply not safe.
The ‘solutions’ from health bosses are just making things worse. They’re trying a short term fix of destroying rural maternity care and prioritising Telford’s Obstetric Unit – but reducing overall capacity is adding to the pressure on beds and staff at both Telford and Shrewsbury. This is no substitute for sorting out staffing across the service.
SaTH decided over a year ago to close the rural Maternity Units in Ludlow, Oswestry and Bridgnorth, to save money. They failed to get away with it last year, because of massive public opposition. Now they’re trying to do it through underhand means. When there is sickness at Telford’s Obstetric Unit, they close down the rural Maternity Units and move their midwives up to Telford. SaTH managers are choosing to do this. It would make more sense to sort out the pressures that are causing such terrible sickness rates in Telford. It would make sense too to try and fill any temporary staff shortfall with bank or agency staff, rather than just getting rid of a valued rural service. And if there are longer term staff shortages – we are certain there are but SaTH repeatedly denies this – then they need a determined recruitment drive. It would also make sense, you might think, to read the national guidance that says hospital trusts shouldn’t prioritise Obstetric Unit care and sacrifice midwife-led units – and ensure safe staffing for both.
But, no. Ludlow and Oswestry have been closed for most of June. In theory they could re-open on 11th July, but that has to be taken with a large pinch of salt. Bridgnorth is closed at the moment, and has been closed repeatedly this month. They want rid of them – probably taking away inpatient postnatal care initially, as a prelude to closing the Units altogether a few months later.
The games playing with local rural services is causing immediate and unacceptable risk to women and babies.
We have had two women give birth without midwife support in the last few weeks, as a direct result of Maternity Unit closure. On 7th May, the baby of Ludlow maternity campaigner Ally Hiles was delivered by her Dad – and the midwife arrived an hour after the baby was born. SaTH didn’t apologise for putting lives at risk – just for Ally not having had her ‘place of birth’ choice! It’s an organisation in denial.
In the early hours of Saturday 17th June, another Ludlow woman went into labour, in a booked home birth. It took a shocking two and a half hours for the midwife to arrive. Fortunately paramedics were nearby and arrived to give support, but it was a terrifying and distressing ordeal for the mother – and a situation that without question created unnecessary risk for her and for her baby.
The response from SaTH quite literally beggars belief. It is also really genuinely offensive that their story was cobbled together without having the courtesy to find out from the woman concerned what had actually happened.
- SaTH whittles down the delay by using the third phone call to their service as the starting point, and ignoring the first two. They pretend that the first midwife arrived after an hour and 12 minutes. They arrive at this figure by calculating the time that elapsed from that third phone call – from paramedics who couldn’t understand why on earth the midwife wasn’t there! SaTH is ignoring the first two phone calls to their midwife service.
- SaTH claims that because this was a planned home birth, the closure of Ludlow Maternity Unit made no difference. That’s nonsense, because the mother is very clear she would have preferred to use Ludlow Maternity Unit if health bosses had not repeatedly closed it. They didn’t bother to ask her before getting their denials out to the media.
- SaTH tries to attribute the delay to road works – but there were no road works in the vicinity that night that explain why a midwife based in the Ludlow area took two and a half hours (or even an hour and 12 minutes) to travel to a Ludlow address.
- SaTH forgets to mention that their two midwives arrived without basic equipment, and that the first midwife was delayed because she tried for 20 minutes to gain entry to the closed Ludlow Maternity Unit to pick up her kit. Apparently her bosses hadn’t got around to telling her that they’d closed Ludlow Maternity Unit and she wouldn’t be able to get in! This isn’t the fault of the midwife – but it’s a shocking breakdown in communication, and no way to run a service.
The response from SaTH is not one of honesty and openness. If they are incapable of acknowledging a catalogue of errors, and the very real risks to the mother and her baby, how can they possibly hope to make sure that these problems never happen again?
It is scandalous that two local women have given birth unsupported by midwives, only a few weeks apart.
This is not a safe service. It is a matter of time until a woman or her baby dies unnecessarily, either because of the pressures at Telford, or because the rural Maternity Units are closed, or because the community service is so badly under-resourced. It is urgent that SaTH sorts this out. If they can’t, then Shropshire CCG – the commissioners of the service – need to stop pretending that this is nothing to do with them. It is their job, too, to ensure the safety of the service. They have a pot of money in reserve, set aside for rural maternity care. This could pay for bank or agency staff for Telford, allowing the rural midwives to immediately return to their own jobs. This needs to happen now, to take some of the pressure off Telford’s Obstetric Unit and to bring back a vital service for women in rural areas.
A Crisis That Won’t Be Fixed By Denial
SaTH likes to do its ‘business as usual’ routine – and SaTH insists it has enough midwives, no recruitment difficulties, and a safe maternity service. We’re seeing a service in a mess, and service managers who have lost the habit of honesty. A culture where only ‘good news stories’ are allowed is putting lives at risk.
Bereaved parents, maternity campaigners, and campaigners against NHS cuts and closures are coming together to say ‘Enough is enough’. We need safe and consistent maternity care for ALL mothers and at ALL local maternity sites. We’re asking you to join the peaceful protest on Tuesday 27th June, at 3.30 pm, outside the Shropshire Education and Conference Centre at the Royal Shrewsbury Hospital. This is right at the end of the main slip road in the hospital, on the right hand side. This is outside the meeting that parents who have lost their babies are not allowed to attend. It seems like the best opportunity we have to say to Shropshire’s Health bosses, ‘How dare you?’ Babies and children are very welcome to be at Tuesday afternoon’s protest.