Monthly Archives: December 2020

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

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