Last week Donna Ockenden published her long awaited report on maternity failings at Shrewsbury and Telford Hospital NHS Trust addressing what has been described as the worst maternity scandal in NHS history. Ockenden’s report revealed last week that 201 babies had died and 94 suffered brain damage as a result of avoidable mistakes. It also established that 9 mothers died because of errors in care.
Following her report, Ockenden said that the lessons from her report “should be learned across the wider NHS”, she also highlighted that there had been “a failure to listen, a failure to investigate, a failure to learn, and a failure to change — and therefore a failure to safeguard patients”.
Following on from the publication of this report, it has emerged today that police are investigating the deaths of two babies during their deliveries at the same trust last year. These cases were among a total of 600 examined by West Mercia police alongside Ockenden’s investigation. It is understood that detectives investigate the care provided on both an organisational and individual level.
If the way in which the trust organised/managed its maternity services amounted to a gross breach of duty and is found to have caused the deaths then the Trust could be found guilty of corporate manslaughter and face an unlimited fine. Any individual found guilty of gross negligence manslaughter could go to jail.
Partner and Medical Negligence specialist Simon Mansfield comments:
This is not the first time that corporate manslaughter charges have been considered following a maternity scandal. Last year the independent reported that charges were being considered against East Kent Hospitals University NHS Foundation Trust after Dr Bill Kirkup’s report revealed that many babies had died at the trust between 2014 and 2018, while more than 100 others suffered brain damage during birth.
It remains to be seen whether charges will be brought but a common theme coming out of these investigations is the failure to listen, investigate, learn, and change as identified by Donna Ockenden in her report. Her concerns are also shared by Professor Ted Baker, the outgoing chief inspector of hospitals for the CQC, who on Times radio yesterday described a culture of deny, deflect and blame which he said was standing in the way of improving patient safety.
To address these issues Professor Baker has called for a change to our regulations to give the CQC powers to take enforcement action against a trust if there is suppression of, or detriment to, whistleblowers. He has also backed calls for regulation of NHS managers, which would make them subject to codes of conduct and liable to being struck off, like doctors.
Both of these proposals are important and as Professor Baker says it is not about punishing managers but treating them with respect as professionals and encouraging them to challenge the prevailing culture where there is a need for change.
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