Mothers and babies died due to a “toxic” culture at an English NHS trust – according to a leaked report on what is being described as the largest maternity scandal in NHS history.
It seems substandard care at the Shrewsbury and Telford NHS Trust not only led to deaths but also caused permanent disability for some children.
Clinical errors were compounded by substandard follow-up investigations that failed to ensure lessons were learnt, while bereaved families were treated with “a distinct lack of kindness and respect”.
The report details clinical malpractice over nearly 40 years that led to the deaths of at least 42 babies and three mothers.
More than 50 children also suffered permanent brain damage after being deprived of oxygen during birth, and the investigation also identifed 47 other cases of substandard care.
More than 600 cases of clinical malpractice are now being examined, involving repeated failings by doctors, midwives and hospital bosses.
As hundreds of cases have yet to be checked, the list of casualties is likely to grow.
The leaked report identifies:
- A long-term lack of informed consent for mothers choosing to deliver their babies in midwifery-led units – where risks can be higher if problems occur – which “continues to the present day”
- A long-term lack of transparency, honesty and communication with families when things go wrong. This supported a culture that was “disrespectful” to families who had been “damaged” as a result
- Failure to recognise serious incidents. Many families who had undergone horrific experiences were told they were the only ones and lessons would be learnt. The report said: “It is clear this is not correct”
- A long-term failure to involve families in investigations that were often poor and described as “extremely brief” and “overly defensive of staff”
- A lack of kindness and respect to parents and families with multiple examples of deceased babies given the wrong names in writing or referred to as “it”
- Not sharing learning, meaning “repeated mistakes that are often similar from case to case”. Failure to learn was present from the earliest case of a neonatal death in 1979 to cases occurring at the end of 2017
- A lack of support for families who have “experienced significant loss and tragedy”
- A long-standing culture at the trust “that is toxic to improvement effort”
The new report is not the result of action by the NHS or the government, though.
It seems the scandal would have remained secret if not for the actions of a family the trust had mistreated.
The Stanton-Davies family had lost a baby daughter in 2009 after midwives failed to monitor her condition – among myriad other failures.
They had to fight for an inquest. Once it proved their daughter’s fate had been avoidable, the family challenged the NHS to re-examine its investigation of the circumstances of the child’s death.
That review revealed systemic failings which enabled the family, with the parents of a second baby, to persuade then-Health Secretary Jeremy Hunt to order an investigation in 2017.
The scale of this scandal is huge – and can only increase.
At this point, This Writer can only echo the words of mother Rhiannon Davies, whose determination to find out why her daughter died has taken matters this far:
“How has this been tolerated for so long? It is horrific.”
Source: NHS Trust’s ‘toxic’ culture led to mother and baby deaths | Central – ITV News
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