Baby Loss Awareness Week 2023

The chairman of Bradford Teaching Hospitals Trust, Dr Max Mclean, has resigned in protest at baby death 'cover-ups-'.

The death of any baby should be considered nothing less than catastrophic. A Perinatal Mortality Review tool, (PMRT), should be used to investigate all baby deaths after 22 weeks. The Health and Safety Investigation Board, (HSIB), investigate cases that meet certain criteria and where an infant is born at term, (37 weeks gestation), and delivered by labour. The purpose of these bodies is to review medical care, understand what happened, and why, and whether certain standards have been met or there have been system failures. The overriding objective is lessons learned for staff, recommendation, and ultimately improvements in patient safety.

But what if these aims are not being met?

It is reported in the Times that Dr Max Mclean, chairman of Bradford Teaching Hospital Trust, has resigned in protest of the inaction by the trust after serious concerns were raised about the performance of the Chief Executive, Professor Mel Pickup, who was appointed to that senior role in 2019.

In a bold move, he called for new leadership at the trust, writing to the head of NHS England. He raised concerns over whistleblowers being ignored stating, 'Patients are at risk, babies are at risk, and there could be avoidable deaths unless there is a change of leadership'.

Despite nine serious issues about Pickup's performance , which were confirmed by an independent investigation on October 2nd, the trust decided there would be no further action. The main concern relates to a delay in investigation of 3 neonatal incidents, involving the deaths of two newborn babies and a third with a permanent disability.

The common themes were failures of an infection, prevention and control.

Investigations that should take place within 60 days, took 14 months. Parallels were drawn with the failure to share information in the Lucy Letby case.

Learning should lead to improved and better outcomes. A failure to share, halts progress. The system should not harbour protection over prevention.

It's about time someone called out this behaviour. It is not surprising that in the Bradford trust they have sought to defend the criticisms in the face of such public criticism. The report by the trust did not recommend escalation to external regulators and issued a statement to say, 'the trust takes concerns regarding patient and staff safety extremely seriously and conducts thorough investigation where necessary'.

This is not a problem limited to this trust. I have seen investigation reports that aren't thorough, which add insult injury. I have seen significant extensions and revisions when the shortcomings have been printed out. Others, make recommendations which should be actioned, but with the same problems featuring later in Maternity Reviews. In one example alone I have seen evidence of ; not enough staff; no clear system to prioritise and risk assess; No fresh eyes policy in line with guidance and Inaccurate documentation. When the same problems are flagged after the trust are on notice of them and make 'recommendations' It devalues the purpose and strength of the reports, and of the catastrophic loss and human impact.

My Clients want to be heard, and it takes courage to find a voice.

For Dr Mclean to feel so strongly as to resign, suggests that there is a difficulty being heard by those that speak out, and about complacency with poor practice and bad behaviour.