Search the hub

A previously secret report into children’s services at a scandal-hit NHS hospital has revealed concerns over the safety of services including care of seriously ill babies were raised with managers back in 2015. A report by the Royal College of Paediatrics and Child Health (RCPCH) raised serious concerns over children’s services at East Kent Hospitals University Trust in 2015 including senior consultants refusing to work beyond 5pm and a shortage of nurses and junior doctors. It also found the neonatal intensive care unit was being staffed by general paediatric doctors instead of specialist neonatal consultants. The confidential report was given to The Independent and posted on the trust’s website this week after being mentioned in the terms of reference for an independent inquiry examining dozens of baby deaths at the trust. It had never been published by the trust, which three years later had its children’s services rated inadequate. A second major report by the Royal College of Obstetricians and Gynaecologists in 2016 highlighted concerns that were not acted on and later featured in the avoidable death of baby Harry Richford, in 2017 which sparked the scandal into dozens more deaths and brain injuries. Bill Kirkup, who is leading the inquiry into East Kent’s maternity services, previously recommended Royal College reviews be registered with the CQC and shared openly by NHS trusts. In its report, the RCPCH said there was “resistance from some consultants to work extended hours” across the trust’s different services with signs of clinicians worked in silos at the different hospitals run by the trust. It warned that paediatric consultants were “spread too thinly across the service” and consultants were providing specialist clinics based on their interests rather than local need. There was “insufficient middle grade doctors to cover both sites” and there were “too few skilled nurses on the wards.” Read full story Source: The Independent, 24 March 2021

There was a "gross failure in basic care" which led to a baby being starved of oxygen during birth, a coroner said. Zak Ezra Carter died at the Royal Gwent Hospital, Newport, two days after being born in July 2018 at Ystrad Fawr Hospital in Caerphilly county. Gwent coroner Caroline Saunders said the monitoring of Zak and his mother Adele Thomas fell "well below the standards expected". She said she was reassured the health board had taken steps to improve care. Ms Thomas told the Newport hearing she felt "scared" and staff "didn't care" when she arrived to give birth on 20 July 2018. In a statement to the inquest she described being turned away from the centre after going into labour on three occasions, before being admitted on the fourth. Ms Thomas said she was initially offered paracetamol as pain relief at the midwife-led centre. She described "a lot of arguing between nurses", one of whom was "bolshie and rude and rough handled me", adding the midwives "did not appear to be in any rush". When Zak was born, he was described as being "white and pale" and without a heartbeat. He did not cry and was taken away to a room for resuscitation. Zak was transferred to the Royal Gwent Hospital where he died two days later. During the first stage of labour, Prof Sanders said "everything was progressing at a normal healthy rate and the fetal heart rate was recorded as completely normal". But she said it was "highly unusual" for the heart rate to not be documented contemporaneously, and the midwives had not been able to explain why they had not done so. Recording a narrative conclusion, Ms Saunders said the monitoring of Ms Thomas and her baby had "fallen well below the standards expected", leading to a "gross failure in basic care" of them in the later stages of labour. Read full story Source: BBC News, 18 March 2021

A baby boy was starved of oxygen and died after being left half-delivered for almost a quarter of an hour during a “chaotic” breech birth in an NHS maternity unit. Midwives failed to recognise baby Theo Ellis was in the breech, or bottom first, position until his mother Laura Ellis, 34, was already in advanced labour at Surrey’s Frimley Park Hospital. What followed was a catalogue of errors by midwives and doctors who failed to heed the emergency situation and raised the alarm too late. At one stage a paediatrician was made to stand outside the room by midwives while junior staff struggled to deliver Theo alone. A senior obstetrician was in surgery and a miscommunication by midwives and an on-call consultant meant she did not arrive until Theo was already dead. After his parents brought legal action against the NHS, Frimley Park Hospital has now admitted mistakes led to Theo’s death in April 2019. Ms Ellis and husband James are angry their son was classed as being stillborn which meant a coroner was not allowed to investigate his care during an inquest. There have been repeated calls to change the law to ensure the deaths of babies like Theo are investigated. His mother told The Independent: “I walked in with a healthy baby. I’d looked after him for nine months and they killed him in the process of giving birth. The hospital get to write that he was stillborn, which obviously is a huge benefit to them, because the coroner can’t get involved, which to me is just staggering." Read full story Source: The Independent, 9 March 2021

Making maternity wards safer for mothers and babies will need £400m of extra spending every year, hospital leaders have told The Independent. They warn that without increased funding, the NHS will not be able to fully implement recommendations made by an inquiry into poor maternity care at the Shrewsbury and Telford Hospitals Trust – where dozens of babies died or were left brain damaged in the largest maternity scandal in NHS history. Multiple maternity care failings at hospitals across the country in the past 12 months have sparked concerns over the safety of mothers and their babies with MPs on the Commons Health Select Committee launching an investigation into the issue last year. Hospital leaders say even just covering existing shortfalls of 3,000 midwives and recruiting 20 per cent more obstetricians, will cost at least £250m a year. To pay for extra anaesthetists, neonatal nurses and other support staff could push the cost to more than £400m. Chris Hopson, chief executive of NHS Providers, which represents hospital trusts, told The Independent that ministers faced a choice of either making the extra cash available or forcing the NHS to cut money elsewhere. In a letter to MPs on the committee, Mr Hopson urged them to demand extra funding in its forthcoming report on maternity safety in an effort to force ministers to confront the issue. Read full story Source: The Independent,9 February 2021,

Failures to follow national guidelines to prevent group B Strep infections in newborn babies is leading to a postcode lottery of care and opportunities to stop deadly infections being missed, a new report has found. Nearly 90% of hospitals in the UK are not using the recommended test for GBS carriage – which costs around £11- despite clear guidance issued by the Royal College of Obstetricians and Gynaecologists (RCOG) and Public Health England (PHE) that the test can significantly decrease false-negative results. Group B Strep is the UK’s most common cause of severe infection in newborn babies, causing sepsis, pneumonia, and meningitis. Approximately 800 babies a year in the UK develop group B Strep infection in their first 3 months of life, 50 babies will die, with another 70 survivors left with life-changing disabilities. Most of these infections could be prevented. Only a tiny number of NHS Trusts are following the key new recommendations around giving pregnant women information on group B Strep, offering testing to some pregnant women, and following Public Health England guidelines on testing for group B Strep. As a result, pregnant women face a postcode lottery, potentially receiving significantly different care from recommended practice. Read full story Source: Group B Strep Support, 1 February 2021

A newborn baby died after doctors caring for him failed to realise that the umbilical venous catheter (UVC) through which he was being fed and medicated was wrongly positioned, a coroner has found. Anna Crawford, assistant coroner for Surrey, called for guidelines from the National Institute for Health and Care Excellence (NICE) on the use of the catheters after hearing that none currently exist. Yo Li was born extremely prematurely at St Peter’s Hospital in Chertsey on 11 January 2019 and transferred to the neonatal intensive care unit, where he was put on mechanical ventilation. A UVC was inserted but it was wrongly positioned within his liver tissue and he died four days later. Read full story (paywalled) Source: BMJ, 29 January 2021

Rachel Hardeman has dedicated her career to fighting racism and the harm it has inflicted on the health of Black Americans. As a reproductive health equity researcher, she has been especially disturbed by the disproportionately high mortality rates for Black babies. In an effort to find some of the reasons behind the high death rates, Hardeman, an associate professor at the University of Minnesota School of Public Health, and three other researchers combed through the records of 1.8 million Florida hospital births between 1992 and 2015 looking for clues. They found a tantalising statistic. Although Black newborns are three times as likely to die as White newborns, when Black babies are delivered by Black doctors, their mortality rate is cut in half. "Strikingly, these effects appear to manifest more strongly in more complicated cases," the researchers wrote, "and when hospitals deliver more Black newborns." They found no similar relationship between White doctors and White births. Nor did they find a difference in maternal death rates when the doctor's race was the same as the patient's. Read full story Research paper Source: The Washington Post, 9 January 2021

In a Letter to the Editor published in The Times yesterday, the All Party Parliamentary Group on First Do No Harm Co-Chair Baroness Julia Cumberlege argues in favour of the work of the Independent Medicines and Medical Devices Safety (IMMDS) Review and its report 'First Do No Harm'. "Inquiries are only as good as the change for the better that results from their work." Read full letter (paywalled) Source: The Times, 5 January 2021

All NHS trusts in England have been given a deadline of Monday to enact safety improvements in maternity care amid Shropshire's baby deaths scandal. Heath chiefs have told hospitals they must have the 12 "urgent clinical priorities" in place by 17:00 GMT. The move is to address "too much variation" in outcomes for families. It comes during a probe into the maternity care of more than 1,800 families in Shropshire. The inquiry, launched amid concerns of repeated failings at Shrewsbury and Telford Hospital NHS Trust (SaTH), focuses on the experience of 1,862 in total, and includes instances of infant fatality. An interim report published last week found poor care over nearly two decades had harmed dozens of women and their babies. The report called for seven "essential actions" to be implemented at maternity units across England. But that has since been transformed into 12 clinical tasks, including giving women with complex pregnancies a named consultant, ensuring regular training of fetal heart rate monitoring, and developing a proper process to gather the views of families. The directions are revealed in a letter in which NHS England says there is "too much variation in experience and outcomes for women and their families". Read full story Source: BBC News, 15 December 2020

Patient Safety Learning Press Release 10th December 2020 Today the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust published its first report on its findings.[1] The report made recommendations for actions to be implemented by the Trust and “immediate and essential actions” for both the Trust and the wider NHS. The Review was formally commissioned in 2017 to assess “the quality of investigations relating to new-born, infant and maternal harm at The Shrewsbury and Telford Hospital NHS Trust”.[2] Initially it was focused on 23 cases but has been significantly expanded as families have subsequently contacted the review team with their concerns about maternity care and treatment at the Trust. The total number of families to be included in the final report is 1,862. These initial findings are drawn from 250 cases reviewed to date. This is another shocking report into avoidable harm. We welcome the publication of these interim findings and the sharing of early actions that have been identified to make improvements to patient safety in NHS maternity services. We commend the ambition for immediate responses and action. Reflecting on the report, there are a number of broad patient safety themes, many of which have been made time and time again in other reports and inquiries. A failure to listen to patients The report outlines serious concerns about how the Trust engaged and involved women both in their care and after harm had occurred. This was particularly notable in the example of the option of having a caesarean section, where there was an impression that the Trust had a culture of wanting to keep the numbers of these low, regardless of patients’ wishes. They commented: “The Review Team observed that women who accessed the Trust’s maternity service appeared to have little or no freedom to express a preference for caesarean section or exercise any choice on their mode of deliver.” It also noted a theme in common with both Paterson Inquiry and Cumberlege Review relating to the Trusts’ poor response to patients raising concerns.[3] The report noted that “there have also been cases where women and their families raised concerns about their care and were dismissed or not listened to at all”. The need for better investigations Concerns about the quality of investigations into patient safety incidents at the Trust is another theme that emerges. The review reflected that in some cases no investigation happened at all, while in others these did take place but “no learning appears to have been identified and the cases were subsequently closed with it deemed that no further action was required”. One of the most valuable sources for learning is the investigation of serious incidents and near misses. If these processes are absent or inadequate, then organisations will be unable to learn lessons and prevent future harm reoccurring. Patient Safety Learning believes it is vital that Trusts have the commitment, resources, and frameworks in place to support investigations and that the investigators themselves have the right skills and training so that these are done well and to a consistently high standard. This has not formed part of the Report’s recommendations and we hope that this is included in their final report. Lack of leadership for patient safety Another key issue highlighted by the report is the failure at a leadership level to identify and tackle the patient safety issues. Related to this one issue it notes is high levels of turnover in the roles of Chief Executive, executive directors and non-executive directors. As part of its wider recommendations, the Report suggests trust boards should identify a non-executive director who has oversight of maternity services. Good leadership plays a key role in shaping an organisations culture. Patient Safety Leadership believes that leaders need to drive patient safety performance, support learning from unsafe care and put in place clear governance processes to enable this. Leaders need to be accountable for patient safety. There are questions we hope will be answered in the final report that relate to whether leaders knew about patients’ safety concerns and the avoidable harm to women and their babies. If they did not know, why not? If they did know but did not act, why not? Informed Consent and shared decision-making The NHS defines informed consent as “the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead”.[4] The report highlights concerns around the absence of this, particularly on the issue of where women choose as a place of birth, noting: “In many cases reviewed there appears to have been little or no discussion and limited evidence of joint decision making and informed consent concerning place of birth. There is evidence from interviews with women and their families, that it was not explained to them in case of a complication during childbirth, what the anticipated transfer time to the obstetric-led unit might be.” Again this is another area of common ground with other recent patient safety reports such as the Cumberlege Review.[5] Patient Safety Learning believes it is important that patients are not simply treated as passive participants in the process of their care. Informed consent and shared decision making are vital to respecting the rights of patients, maintaining trust in the patient-clinician relationship, and ensuring safe care. Implementation for action and improved patient safety In its introduction, the report states: “Having listened to families we state that there must be an end to investigations, reviews and reports that do not lead to lasting meaningful change. This is our call to action.” Responding with an official statement in the House of Commons today, Nadine Dorries MP, Minister for Mental Health, Suicide Prevention and Patient Safety, did not outline a timetable for the implementation of this report’s recommendations. In 2020 we have seen significant patient safety reports whose findings have been welcomed by the Department of Health and Social Care but where there has subsequently been no formal response nor clear timetable for the implementation of recommendations, most notably the Paterson Inquiry and Cumberlege Review. Patient Safety Learning believes there is an urgent need to set out a plan for implementing the recommendations of the Ockenden Report and these other patient safety reports. Patients must be listened to and action taken to ensure patient safety. [1] Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Emerging findings and recommendations form the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, 10 December 2020. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2020/12/ockenden-report.pdf [2] Ibid. [3] The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, 2020. https://assets.publishing.serv...; The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf [4] NHS England, Consent to treatment, Last Accessed 16 July 2020. https://www.nhs.uk/conditions/consent-to-treatment/ [5] Patient Safety Learning, Findings of the Cumberlege Review: informed consent, Patient Safety Learning’s the hub, 24 July 2020. https://www.pslhub.org/learn/patient-engagement/consent-and-privacy/consent-issues/findings-of-the-cumberlege-review-informed-consent-july-2020-r2683/