Shocking news emerged yesterday from Shropshire NHS of the death of at least 42 babies and three mothers. Further, more than 50 babies (or adults as they possibly are now) suffered brain damage during labour.
This is probably by far the worst scandal in the history of medical practice in the UK in recent years. Incredibly, despite repeated assurances from the NHS hierarchy that they now believe in transparency and in upholding their duty of candour, the story has only emerged as a result of a leaked report.
The leaked report covers hundreds of incidents from 1979 to 2017. The Independent newspaper, which received the leaked report says that it talks of a “toxic” culture of uncaring staff, who treated grieving families quite callously and dismissed their concerns out of hand.
Staff could not even get babies’ names right and in one awful example of inhumanity , referred to a baby who had died as “it”.
The leaked document said a review carried out by the Royal College of Obstetricians and Gynaecologists (RCOG) in 2017 was inadequate, and it criticised the “misplaced” optimism of the regulator in charge in 2007, which said improvements could be made to the trust’s maternity services.
The initial scope of the inquiry was to examine 23 cases but this has now grown to more than 270.
The figures in the report are truly shocking :
- 22 stillbirths
- 3 deaths during pregnancy
- 17 neonatal deaths
- 3 maternal deaths
- 47 cases of substandard care
- 51 cases of avoidable brain damage at birth
Some of the most tragic failures identified in the report are:
- Babies suffered brain damage because of staff failings, this was primarily due to poor monitoring of heart rates during labour
- Some babies suffered brain damage as a result of not giving antibiotics – to treat Strep B and
- Many families could not get proper answers from the trust after incident of death/ brain damage
- A family were told they would have to leave the hospital if they did not “keep the noise down” following their distress at death of their new born baby.
- Bereaved families were routinely advised that their case was a “one off event” and “lessons would be learned”.
The scandal dwarfs the previous appalling events at Morecambe Bay, where the deaths of 11 babies and one mother were linked to an uncaring and unprofessional culture.
The families of Bristol Royal Infirmary baby scandal must also be questioning whether anything has really changed in the past 30 years in NHS culture. Also I am reminded of the same staff toxic culture which existed at Gosport War Memorial Hospital where more than 450 patients died after being given powerful painkillers inappropriately. It was found that a practice of almost routine use of opiates before death was in place and the words found in one set of patient notes before death were : “Please make comfortable” which was said to be a euphemism that staff used when giving opiates.
The Duty of Candour was implemented by the NHS in 2015 following the appalling treatment of patients at Mid Staffordshire NHS where hundreds of hospital patients died as a result of substandard care between January 2005 and March 2009. The Mid Staffordshire trust, was said to have “lost sight” of its responsibility to provide safe care.
Again a report will be produced making various recommendations but a more fundamental shift in the culture of the NHS is clearly needed.
How do these pockets of awful and unsafe care remain unrecognised, unaudited and unsupervised despite the numbers of NHS managers ?
What kind of data is the NHS using (if any) to identify outlier NHS trusts where there are higher than average claims relating to brain injured children?
Is the Duty of Candour being enforced ?
Are tougher penalties need for failing to apply the Duty of Candour?
Can the NHS do more to encourage whistle-blowers ?
Several countries, such as the U.S., Canada and South Korea, have introduced whistleblower reward programmes that aim to increase the quantity of disclosures about cases of misconduct in business and government. These have proved to be effective. It would be a sad day that one would have to introduce such a scheme into the NHS – to essentially reward appropriate behaviour – but maybe this is what is needed to stop the scandals from recurring ?