Maternity scandals in the UK – a recent history
A recent BBC documentary looked at the tragic events involved in the Shrewsbury & Telford Hospital NHS Trust maternity scandal, but sadly this is not the first, or last, scandal of this type to happen to mothers in the UK. We look back at the last twenty years of maternity care scandals.
We have supported bereaved parents for over a decade. It has been a privilege to help families get their desperately needed answers to questions, and justice for their baby. The ultimate aim of the parents and legal process is to try and ensure that lessons are learnt from the mistakes made or inappropriate guidelines updated, so that no other parent has to go through the same heartache.
Generally, we feel reassured by the Trusts we speak to that this is being achieved. However, when the Trust itself doesn’t learn from its own mistakes, or worse, refuses to acknowledge that their actions are not in the best interest of mum or baby and that change is desperately needed throughout the organisation, the result can be devastating failures and life-changing impacts for the families involved.
Northwick Park Hospital (part of London North West University Healthcare NHS Trust)
The Trust performed an internal investigation after 10 mothers had passed away during pregnancy or within 42 days of giving birth between April 2002 and April 2005, which was six times the national average. This was followed by an independent investigation by The Healthcare Commission (a Government department which was previously responsible of assessing the quality of NHS care) with its final report being published in August 2006. The Hospital was also put into special measures.
The Healthcare Commission found that the mothers’ deaths were caused by a combination of system failures, inappropriate working culture, staff shortages, weak leadership and a poor quality of care in 9 out of the 10 cases. These failures meant that decisions about care weren’t made at the appropriate level and changes in risk to mum and baby weren’t recognised. The Healthcare Commission also emphasised the need for robust systems to be in place to monitor the safety of maternity care generally.
Following the inquiry, substantial changes were made and there appeared to be an improvement in care. Three further maternal deaths were reviewed in 2008, however, no organisational failures were found.
Sadly, in June 2021, the Hospital was rated ‘inadequate’ by the Care Quality Commission (CQC – the body which has largely take over the Healthcare Commissions role and acts as an independent regulator). The Hospital was inspected after eight babies died in five weeks and significant concerns were raised regarding the culture, including bullying of staff and inappropriate patient interactions.
University Hospitals of Morecambe Bay NHS FT
The Morecambe Bay investigation was set up in 2013 to examine concerns over a number of maternal and baby deaths which occurred between 2004-2013.
The Kirkup report published in 2015 concluded that the maternity unit was dysfunctional and serious failures of clinical care led to the avoidable deaths of 11 babies and one mother.
The report highlighted serious problems in clinical competance and poor working relationships between midwives, obstetricians and paediatricians. There was a culture of ‘over-zealous’ pursuit of natural childbirth ‘at any cost’ and failures in risk assessing and care planning. The report identified there were repeated failures to investigate properly to ensure lessons were learnt.
The Trust was in special measures between 2014-2016. A recent CQC inspection raised concerns of the Trust including maternity, which dropped from ‘good’ to ‘inadequate.’
Shrewsbury & Telford Hospitals NHS Trust
An Inquiry (The Ockenden Review) into the maternity care provided by Shrewsbury and Telford Hospital NHS Trust is currently reviewing the care provided to 1,862 former patients over a 20 year period. These include cases of stillbirth, neonatal death, maternal death and other severe complications for mothers and newborn babies.
The initial report published in December 2021 was based on a review of 250 cases. This identified there was a lack of compassion and kindness, failure to provide adequate information regarding place or type of birth, poor consultant oversight of high risk pregnancies, lack of escalation of concerns (from midwives to obstetricians and from junior obstetricians to consultants), significant problems relating to monitoring babies and induction and traumatic births. It was identified that the Trust had developed its own ‘High Risk Case Review’ which resulted in fewer instances being reported to the NHS Regulators limting the opportunity to learn lessons.
Caesarean rates at Shrewsbury and Telford Trust were between 8-12 % lower than the England average. There have been occasions where this has been positively reported, in line with the with government target which they were consistently below.
The initial findings from the inquiry show that there were cases where an earlier decision for caesarean section rather than a persistence towards a “normal delivery” may have avoided harm to babies and mums.
A further report will be published next month.
Cwm Taf Morgannwg University Health Board
A review was conducted by the Royal College of Obstetricians and Gynaecology and the Royal College of Midwives in 2019 following concerns about the death of a number of babies at Royal Glamorgan Hospital and Prince Charles Hospital potentially due to staff shortages and a failure to report serious incidents.
The review investigated 43 pregnancies (including 21 stillbirths, 5 neonatal deaths and 17 complications in labour) between 2016 – 2018. The report found that there was inadequate support for junior doctors, unacceptable consultant cover out of hours, lack of awareness of guidelines, unacceptable midwife staffing levels and a blame culture in the service.
An Independent panel was set up by the Welsh Government in 2019 to oversee improvements after the Trust was placed in special measures. They reviewed 63 cases and found major failings in 21 cases and that lessons could be learnt in 48. The report found a third of babies stillborn may have survived were it not for serious mistakes at the Trust.
The second phase of the review focused on the care 27 women received most of whom were admitted to ICU between 2016-2018. The review found two thirds of women (19 cases) could have had different outcomes if they had received different management/better care.
A third report will be published later this year.
East Kent Hospitals University NHS Foundation Trust
The Trust was investigated by the CQC in 2020/2021 following concerns raised by a Coroner in January 2020, who concluded that one week old Harry Richford’s death was due to neglect by the Hospital. The CQC found the main issue to be staff shortages (with some midwives working 20-hour days) which meant mums and babies couldn’t receive the care they desperately needed, and sometimes had to be transferred to other hospitals whilst in labour. Other concerns focussed on failures by consultants including not doing ward rounds, not coming in when asked despite being on call and failing to complete mandatory training. These problems caused babies to die unnecessarily, and mums to suffer injuries. Sadly, the Royal College of Obstetricians and Gynaecologists had previously raised concerns in 2016, but these had not been acted upon, meaning an opportunity to improve care had been missed.
A criminal case (the first of its kind) was brought by the CQC which resulted in a £733,000 fine for the Trust in 2021.
In response to the CQC’s findings and further families reporting concerns about their care, the Kirkup Review (a public inquiry) was started in 2021 and is looking at cases between 2009 and 2020. The Review is due to be published this summer/autumn.
Nottingham University Hospitals Trust
An independent inquiry by the Nottinghamshire CCG and NHS England is underway at Nottingham University Hospitals Trust, although there are calls from many for a public inquiry. The inquiry was started in response to a CQC report in September 2020 which rated the Trust’s maternity care ‘inadequate’. The report included familiar themes such as failing to recognise a change of risk to mum and/or baby and then to act on it, meaning that a deterioration in health was not prevented.
The parameters of the investigation can be found here and it is intended to be completed by the end of 2022.
Understandably, a large part of the anger felt by families is the knowledge that the Trust not only made mistakes, but incorrectly graded the severity of mistakes or created new categories for babies who were stillborn, which meant they avoided reporting them nationally. This meant senior members of the Hospital and regulators were not aware of the extent of the problem and lessons were not being learnt.
It has been reported that the Trust has paid over £91m in compensation and legal fees between 2010 and 2020, including 34 deaths and 46 babies who suffered brain damage.
Healthcare Safety Investigation Branch (HSIB) – maternity
Although not strictly a ‘maternity scandal’, the maternity arm of HSIB has been widely criticised recently and will no longer perform its investigative role. HSIB (currently run by NHS England) was created in 2017 to investigate all clinical incidents in the NHS and make recommendations for learning and improvement, without blame. The maternity arm investigates cases where a baby has passed away after reaching 37 weeks in pregnancy, either during labour or within the six days afterwards. They also investigate maternal deaths during pregnancy or within 42 days of the baby being born and babies who are diagnosed with a severe brain injury within 7 days of birth. The intention was to spot any common themes and bring about systemic change. It was seen as a shining light for many who had been impacted by the previous scandals and brought hope that these would be a thing of the past. Sadly, we now know this has not been the case.
Prior to becoming an independent organisation away from NHS England, an external review into HSIB was performed. Sadly, it has been reported by The Health Safety Journal that in the maternity department they found many of the same problems identified in the above hospitals – bullying, widespread cultural problems including a lack of openness to challenge, discrimination and generally unprofessional behaviour throughout the organisation. These issues were found to be damaging to staff mental health and a potential barrier to recommending the change and improvements needed in some Hospitals.
In light of the concerns raised about HSIB maternity investigations a replacement organisation called the Special Health Authority will take over their investigative role in the near future. It is hoped that the previous cultural issues will not be repeated and lessons have been learnt.
How the government is tackling maternity care standards
The Government’s Health and Social Care committee have published their report from the ‘Safety of Maternity Services in England’ Inquiry. This is chaired by Jeremy Hunt and aims to explore and understand why maternity care still has areas of significant concern, despite the work that has gone into improving it. The report was published in July 2021, which identified three main areas of concern,
- Women and babies from ethnic minorities and deprived areas are at greater risk of baby loss and maternal harm.
- Cultural issues which made women feel like failures for having caesarean sections
- Suggested setting up a working group of families and clinicians to address their cultural concerns
- Requirement for additional staffing
A link to the Government response is here. One of the recommendations they have taken on, likely in recognition of the Shrewsbury scandal, is the removal of targets which were used to penalise maternity services for high caesarean rates. It is hoped that this will help aid the cultural changes needed in hospitals so “natural births” aren’t pushed at all costs and mothers feel listened to.
Expert help with maternity negligence and birth injury claims
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