Stuart Bramley, a solicitor specialising in maternity errors comments:
Although most people will be aware of the facts involved in the Telford & Shrewsbury scandal, this BBC article highlights something even more important - the personal experiences of the parents who suffered so much as a result of apparently avoidable mistakes. Reading their accounts is heartbreaking. My colleagues and I often handle legal claims where the same mistake or oversight is repeated in a few different births by the same doctor or midwife, or at the same hospital, but the scale of this tragedy is in a different league. Although we await the outcome of the official report, the fact that so many babies have suffered through apparently poor care is appalling. I sincerely hope parents get more than the usual "Lessons have been learned and changes have been made" attempt to reassure them. They deserve so much more.
Shrewsbury and Telford Hospital NHS Trust scandal
Shrewsbury and Telford Hospital NHS Trust is at the centre of what many have said may be the biggest scandal in the history of the NHS. The report into the failings of care at this NHS Trust is to be published next month.
It all started with an e-mail between two mothers, who were strangers, but a bond formed quickly following the death of their new-born babies.
Baby Pippa
Kayleigh had welcomed her second daughter Pippa into the world in April 2016 and gave birth at home. Pippa arrived safely but on four occasions Kayleigh called her midwifery team with concerns but was told not to worry. The next morning Pipa became unresponsive, so her father Colin started trying to resuscitate her while an ambulance was called. That afternoon Pippa died, at just 31 hours old.
The couple were told she died of an infection, Group B Strep. The Shrewsbury and Telford Hospital NHS Trust said they would carry out an investigation, but weeks passed and the family had heard nothing. After contacting the Trust the couple were informed this would be a purely internal investigation.
Baby Kate
Rhiannon had become pregnant with her first child in 2008 when she was assessed as being a low-risk pregnancy, so was advised to give birth at a midwife-led birthing centre run by the Ame Trust in Ludlow. In the days leading up to the birth, she noticed her baby wasn’t moving as much so reported this to clinicians but was told her baby was just ‘lazy’.
In March 2009 Rhiannon’s baby Kate was delivered, but the mother later felt that something wasn’t right. Rhiannon was told Kate was simply crying but it later transpired this had been a clear sign of respiratory distress. It was clear she needed medical attention but the nearest doctors were 45 minutes away so an air ambulance came to take Kate to a hospital in Worcester. Tragically, Kate did not survive the journey.
The initial report from the trust noted Kate’s death as a “No harm” event. In 2012 an inquest concluded that her death was preventable, and that the lack of movement in the days leading up to the birth should have led to Rhiannon giving birth in hospital.
Mothers investigate
The bond between the two mothers deepened and they started to investigate to identify whether any other families had received poor maternity care at the same Trust. They gathered 23 cases dating back to 2000 and so to the then Health Secretary Jeremy Hunt, asking him to order an investigation. In May 2017 he agreed and the independent senior midwife Donna Ockenden was appointed to lead the review. As that process continued, more failures and avoidable deaths were uncovered.
The inquiry
The interim report from Donna Ockenden has led to nearly £100m additional investment in maternity services in England. Further, last week NHS England wrote to all Trusts telling them to no longer limit the number of caesarean sections they offer women.
When the final report is published next month, it will be a huge moment in the history of the NHS. Pippa and Kate lived less than 40 hours combined, but what has come as a result of their deaths in terms of improved maternity care could last decades.
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