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The Maternity Scandal

The Independent newspaper have recently reported on the failings of The Shrewsbury and Telford Hospital NHS Trust ("SaTH") maternity unit. This is due to a report being leaked, prepared by midwifery expert Donna Ockenden, who has led an independent investigation into more than 600 cases from 1979 to 2018.

The investigation was originally launched by former health secretary Jeremy Hunt, following a number of complaints and was subsequently expanded by current health secretary Matt Hancock whilst the trust's two hospitals, Royal Shrewsbury and the Princess Royal in Telford, were put into special measures.

The report shows at least 42 deaths of babies and three of mothers, as well as 50 cases of babies left with brain damage at SaTH between 1979 and 2017. The cases include 22 stillbirths, three deaths during pregnancy, 17 deaths of babies after birth, 47 cases of substandard care and 51 cases of cerebral palsy or brain damage after being deprived of oxygen during birth.

The report states that staff at the trust were uncommunicative with families and also criticises the trust's slow response in sending the inquiry medical records, clinical notes and other documents, along with the following:

• 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;
• Failure to recognise serious incidents;
• 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". The failure to learn from past mistakes 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".

Bill Kirkup, who chaired the Morecambe Bay NHS Foundation Trust inquiry into the scandal which saw the deaths of 11 babies and one mother between 2004 and 2013 at Furness General Hospital, commented that it made for "ghastly" reading and showed "unmistakable parallels" with the scandal at Furness General Hospital.

What can be done?

The most recent scandal makes for some stark reading and suggests that lessons were not learnt from the short falls at Morecambe Bay NHS Foundation Trust. Currently, the UK ranks 24 out of 49 high income countries in terms of stillbirth rates, with around one in 250 pregnancies ending in stillbirth after 24 weeks gestation. So what can the NHS do?

1. Saving Babies' Lives Care Bundle

Saving Babies' Lives Care Bundle (SBLCB) was launched by NHS England in 2016, in response to the Government's ambition to reduce the rate of stillbirths by 50% by 2030. The SLBCB sets out the following way to potentially improve outcomes for babies and mothers:

• Reducing smoking in pregnancy;
• Risk assessment and surveillance for fetal growth restriction;
• Raising awareness of reduced fetal movements;
• Promoting effective fetal monitoring in labour.

It is important that babies which are small for their gestational age are identified during pregnancy, as they are at a higher risk of low blood sugar and stillbirth. The SBLCB recommends a number of interventions to identify babies at risk.

The initiatives recommended by the SBLCB does comes with increased costs, which will include purchasing new equipment, the increase in the number of scans conducted, investment in training and the increase in intervention such as induction of labour and caesarean sections. However, it is hoped that investing will result in a reduction in expenditure elsewhere, for example saving on testing, post-mortem examinations and litigation. Further details of SBCLB can be found here.

2. Early Notification Scheme

In 2017, NHS Resolution (which acts like an insurer for all NHS hospital trusts) developed an Early Notification Scheme (ENS) for birth injuries which aims to ensure early investigations into whether there was any substandard care where, a baby born at term (at least 37 weeks), at an NHS hospital has a potentially severe brain injury diagnosed in the first week of life. The hospital trust will be required to complete an early notification report form if a baby:

• Has been diagnosed with a grade III hypoxic ischaemic encephalopathy (HIE);
• Has undergone therapeutic cooling; or
• Has decreased central tone and has experienced seizures and is comatose.

3. Healthcare Safety Investigation Branch Maternity Investigations

Additionally, there are now also maternity investigations by the Healthcare Safety Investigation Branch (HSIB), which is independent of NHS Resolution and any NHS hospital. HSIB was established in April 2017 to conduct independent investigations to support rapid learning and patient safety improvement within the healthcare system. HSIB can investigate the care provided to a mother and baby during birth and unlike an ENS investigation they can also investigate stillbirths, early neonatal deaths and some maternal deaths.

HSIB's responsibility for conducting maternity investigations only applies to babies that have reached at least 37 weeks gestation when labour commences, and where there is suspected harm to the baby. If these conditions are met, HSIB will look at the following category of cases:

• Brain injured babies;
• Early neonatal deaths;
• Maternal deaths.

The HSIB maternity investigation report should provide an accurate account of the care received and aim to identify and address any risks in the care provided by NHS hospital, and contribute to improving maternity services in the NHS, which is a positive step forward given the recent damning article.

The stillbirth and neonatal mortality rate has fallen by a fifth in the last decade however given the recent scandal it is clear that more can be done and needs to be done to improve the NHS maternity service. We hope that the relatively new SBLCB and the ENS/HSIB investigations will in time start to improve the mortality rates.

If you have concerns about your previous antenatal or maternity care or if you consider it fell below the proper standard, please contact the Clinical Negligence team on 01254 872111 to discuss the matter further.

Learn more about our Clinical Negligence department here

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