The interim report, written by Donna Ockenden and intended for NHS Improvement and the Trust’s eyes only, was leaked to the press yesterday. Although described as an ‘internal status report’ as at February 2019, its conclusions are damning, covering major failings in maternity units at Shrewsbury and Telford Hospital NHS Trust.
According to the report a ‘toxic culture’ was in place at Shrewsbury and Telford Hospital NHS Trust stretching back 40 years, when babies and mothers suffered avoidable death, despite many assertions that ‘lessons have been learned’ and the legal requirements for a duty of candour.
Scope of review was broadened
Ockenden was commissioned in April 2017 by the then Health Secretary Jeremy Hunt to look into the deaths of 23 babies and mothers, allegedly as a result of poor care, at Shrewsbury and Telford Hospital NHS Trust. The initial scope of maternity expert Donna Ockenden’s report was to examine those 23 cases but her review grew to take into account more than 270 similar tragic cases from 1979 to the present day.
Shoosmiths clients involved
Kamaljit Uppal is one such tragic case under investigation. She lost her son in April 2003 because he became trapped during the delivery and was effectively starved of oxygen. The post mortem report confirmed her baby died as a result of a trapped vaginal breech delivery. A five-month ultrasound scan had established that the infant was breech, but despite her request for a caesarean section, her delivery plan was not changed. Kamaljit was told nothing by the Trust and was not aware anything untoward had happened until she saw the news of the investigation in the media. Kamaljit was subsequently contacted by the Trust and then turned to Shoosmiths for advice.
Failures in clinical oversight, managing and interpreting vital equipment
Maternity care at the Trust has been the subject of no fewer than six separate inquiries, including one by the Royal College of Obstetricians and Gynaecologists in 2017 which Ockenden considered to be “inadequate”. In 2018 the Care Quality Commission (CQC) published a report which rated the services at Shrewsbury and Telford Hospital NHS Trust as ‘inadequate’.
That CQC review highlighted a number of actions that the Trust should take to improve, including the need for all staff complete Cardiotocography (CTG) training (CTG is a technical means of recording the foetal heartbeat during pregnancy). Ockenden too notes that babies were left brain-damaged because staff failed to realise or act upon signs that labour was going wrong or failed to adequately monitor heartbeats during labour or assess risks during pregnancy, resulting in the deaths of some children.
That lack of technical understanding and negligent failure to act upon CTG warning signs is particularly familiar to Shoosmiths in birth injury cases. It was for example the failure by staff (albeit at a different Trust) to interpret a CTG trace correctly that meant there was a delay in delivering James Robshaw, which resulted in him suffering severe cerebral palsy.
Lessons clearly not learned
Even after an apparently successful delivery, Ockenden criticises the standard of care given.
Rushi Kumari, another Shoosmiths clients allegedly suffered brain damage due to the incorrect insertion of a Total Parenteral Nutrition (TPN) tube following her premature birth and subsequent leakage of infant formula into her cerebro spinal fluid that went unnoticed for several hours.
Rushi now needs a special pushchair, a walker and Zimmer frame because she cannot walk long distances and struggles to communicate verbally. The family were assured that the Trust was “committed to making improvements rapidly…” in 2014, but Ockenden suggests there is still much room for improvement, highlighting examples where families were also assured “they were the only family" and that "lessons would be learned". That too is a familiar mantra heard after every other example of medical negligence and avoidable injury or death.
Mothers as well as babies suffered
Ockenden ended up reviewing 22 stillbirths, three deaths during pregnancy, 17 deaths of babies after birth, 47 cases of substandard care, 51 cases of cerebral palsy or brain damage and the death of three mothers. However other mothers, such as Andrea Bates, suffered serious injuries. Andrea was admitted to the Princess Royal Midwifery-led Maternity Unit in Telford in the early stages of labour with her first child in February 2015.
Unfortunately, her labour was long and traumatic, which could have been avoided if staff had acted on her request for a caesarean section. Eventually her daughter was born following a second attempt by forceps.
Thankfully her baby was fit and well, but Andrea was left with significant injuries which have destroyed her confidence and bonding with her baby. She has been unable to return to her previous work and now requires ongoing medical attention.
A toxic and insensitive culture
Ockenden also describes other instances where the wishes of patients were ignored or dismissed and an astounding, but apparently routine, cruel lack of sensitivity in dealing with anxious and often grieving parents. Staff at the Trust consistently dismissed parents' concerns, were unkind, got dead babies' names wrong and in one instance, referred to a baby who died as "it". One family was told they would have to leave if they did not "keep the noise down" when they were upset following the death of their baby.
Kashmir Uppal, a partner in Shoosmiths medical negligence team who has spoken about this Trust previously, said:
“The findings in this leaked document show that the concerns surrounding the Trust are deep rooted and multi factorial. While we look forward to the promised ‘one, single, comprehensive’ report by the independent review team covering all cases of serious concern within maternity services at the Trust, at the very least the families deserve an immediate explanation and an apology. We can only hope that lessons really will be learned from the Ockenden review to ensure better patient safety and a more empathic approach by staff in the future.”