Worcester Maternity Deaths – another whistleblower silenced?

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Pregnant woman having her heart monitored

The Independent today reports that the Clinical Director at Worcester Royal Hospital has raised the alarm that mothers and babies are being put at risk by delays, incorrect prioritisation of patients, bed blocking and understaffing on wards as a result of a “Continuity of Carer” system at the hospital.

Dr Catherine Hillman, Consultant obstetrician and Clinical Director at WRH, posted her concerns about the Continuity of Carer system on an internal Facebook page, saying it was not safe, generated a two-tier system and caused unacceptable delays. She claimed she was asked to change the message by managers but she refused, so it was taken down and replaced with a message supporting the system which she felt she could not support. In response, hospital management has stated that the message was removed at the request of another employee.

Referring to “this shambolic train of events” Dr Hillman said she felt publicly undermined and that her role was no longer tenable – she has also resigned.

Midwives working on the wards said Dr Hillman worked “on the shop floor” with the midwives, was well regarded and had a great relationship with everyone….”she has a voice and even she was shot down”.

In December 2020 a young mother collapsed and died on a maternity ward, and her baby was saved by an emergency Caesarean Section. A CQC inspection in December downgraded the trust’s maternity service and raised concerns over staffing levels.

Worcester Royal said that it had paused any further rollout of the Continuity of Carer model and will be evaluating its impact, and had recruited 17 newly qualified staff to join in September.

A timeline of whistleblowing in the NHS

In recent years there have been several instances of whistleblowing by NHS employees who felt that there were serious flaws in the healthcare that was being provided, but that no action was being taken to correct those flaws.

How does whistleblowing in the NHS work?

Whistleblowing is vital, but can often leave those who hope to make change unemployed, and ostracised by their peers. In his 2015 “Freedom to Speak Up” review, Sir Robert Francis QC recommended that the NHS put a policy into place that would protect whistleblowers. The report was commissioned following the Mid-Staffs scandal in which many patients lost their lives or were injured due to the standard of care that was being provided, and because staff were not empowered to speak out, the situation continued for far longer than it should have. This led the NHS to finally implement an official policy designed to protect those that speak out.

What happened to previous whistleblowers?

1989 – The Bristol Children’s Cardiac Surgery Scandal

On joining the staff at Bristol Royal Infirmary’s paediatric cardiac surgery unit in 1989, consultant anaesthetist Steve Bolsin became concerned that too many babies were dying during their surgery. Although he was able to drastically reduce the rate of deaths in the unit, his frustrations with the hospital’s refusal to investigate what had gone wrong led him to approach the media as a whistleblower. Although his actions led to the improvement of clinical governance across the UK and saved many lives, he was unable to find work in his home country and had to move to Australia.

2001 – Walsgrave overcrowding

In 2001 two patients being held in overcrowded bays in Coventry’s Walsgrave Hospital died after the management introduced a policy of putting more beds into a room than capacity should have allowed. This left staff struggling to fit essential equipment into the rooms, and made patients more difficult to access. Cardiologist Raj Mattu was concerned enough to write to the Trust’s chief executive, but the only result was his suspension. Later in 2001 a CQC inspection confirmed the poor quality of care being provided.

1996-2011 – Ian Paterson, Solihull breast surgeon

When disgraced surgeon Ian Paterson worked for the Heart of England NHS Trust between 1996 and 2011, he performed incomplete “cleavage sparing” mastectomies on over 400 patients without consent, leaving them with a greater risk of the cancer returning. Paterson was also working in a private hospital for Spire at the time, and lied to many of his patients in order to make money from putting them through unnecessary surgery for cancer they did not have. Following his conviction in 2017 for wounding with intent, it was revealed that retired oncologist Dr Andrew Stockdale had raised concerns about Paterson’s NHS practice in 2003, without any result. He had himself then been subjected to an investigation by the GMC. In 2007-8, retired GP Dr Eli Layton had raised concerns about Paterson’s private practice, but again these were not substantively acted on, allowing Paterson to continue harming patients for several more years.

2011 – Royal Wolverhampton Trust coding concerns

In 2011 Sandra Haynes-Kirkbright joined the Royal Wolverhampton NHS Trust as head of clinical coding. The codes are used to record which services a patient has received, and in turn this decides how much funding the hospital needs. She alleged that some of the codes being used had no purpose but to increase income to the trust, and on raising concerns with management was dubbed obstructive and difficult. Although she should have been recognised as a whistleblower, she was instead subjected to disciplinary procedures. An independent report would eventually confirm that Sandra had acted correctly, and she remains employed by the NHS.

2014 – Lewisham and Greenwich NHS Trust

When Chris Day was working as a junior doctor for Lewisham and Greenwich NHS Trust at Queen Elizabeth Hospital in Woolwich between 2013 and 2014, he raised concerns about short staffing of doctors during night shifts. He made a “protected disclosure” to management and Health Education England, the body which oversees the development of junior doctors. Rather than consider his concerns, the trust instead raised counter-allegations against him, and he was forced out of his career as a doctor. An employment tribunal ruled that junior doctors who acted as whistleblowers were not entitled to the same level of protection as a qualified doctor or other full member of staff. It took until 2018 for an employment tribunal to finally reject the HEE assertion that they did not owe juniors any protection, by which time a peer review of the ward in question had raised concerns about staffing, incident reporting and patient safety.

What will happen next for Worcester’s maternity services?

 Worcestershire Acute Hospitals NHS Trust have reiterated their commitment to the Continuity of Carer programme but have paused it, and hope to have filled their advertised vacancies by the end of this month.

They have also promised to carefully evaluate the way Continuity of Carer has been rolled out before making any future plans.

Problems in pregnancy and delivery, including delays and missing warning signs, can lead to devastating injuries for both mothers and babies. If you’ve been affected, you can learn more about our birth injury and maternity negligence services, or contact us.

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