It was announced on 12 April that the Health Secretary, Jeremy Hunt, will be investigating a cluster of baby deaths at the Shrewsbury and Telford Hospital NHS Trust. This was reported nationwide with seven babies and their families being identified. We have acted for some of these families who have had to fight hard to have their questions answered about the circumstances in which the deaths occurred.
Investigations will be specifically looking at failures to appropriately monitor babies’ heart beats during pregnancy and labour which was a contributory factor in at least five of the deaths deemed avoidable. The relevant period was September 2014 to May 2016 and all of the deaths were considered “avoidable”, according to Coroner verdicts at Inquests and within the course of legal action brought against the Trusts.
I understand that one of the allegations is the failure to keep midwives training updated at the Trust. The guidelines for the interpreting of CTG scans have been changed and improved twice in recent years by NICE (National Institute for Health and Care Excellence), but it is all important for midwives and doctors to be carefully trained so that they are able to work within the guidelines.
As the head of the clinical negligence department at Lanyon Bowdler I have long been concerned about the amount of cases referred to us, arising out of alleged mistakes made by the Trust in the delivery of babies causing death and permanent injury.
Fetal heart rate monitoring
One important point to make, however, is that the media has only focused on the babies who have died as a result of failures by the Trust. There are many babies who have survived a traumatic birth, where monitoring has been substandard, but suffered permanent brain damage and most of their cases are probably still being investigated by specialist clinical negligence lawyers.
If a baby’s heart rate is not monitored carefully during labour then the baby can become distressed because of problems such as insufficiency of the placenta or umbilical cord compression, or indeed for unexplained reasons. Fetal heart monitoring is essential so that action can be taken and if necessary babies are delivered quickly if they become compromised.
Not learning from mistakes
At Lanyon Bowdler we are acting for many children who were starved of oxygen during labour and have suffered permanent brain damage. They haven’t tragically died, but many will not be able to live a normal life, without the prospect of employment and a normal family life, relying totally on the support of their families and commercial or state provided care.
A separate analysis of all the NHS Trusts in England last year rated Shrewsbury and Telford as one of the worst in the country when it came to learning from mistakes and incidents, describing the Trust as having a poor reporting culture. In my view learning from a mistake is absolutely essential in any organisation responsible for the safety of individuals.
I am very dismayed to hear that the medical director at the Trust, Dr Edwin Borman, apparently told BBC News that the Trust’s mortality figures were no worse than anywhere else. Does he really think this provides any reassurance to the local community? Culture could be changed by encouraging hospital staff to speak up and warn of situations where there may be safety issues, so that remedial or preventative action can be taken before a patient is injured.
There should be a no blame culture like in the aviation industry so that the focus is on ensuring constant improvement through learning. This would prevent such terrible mistakes happening again and again.