The Sunday Times April 3, 2022 2GN 9NEWS
Police investigating deaths of two
babies last year at scandal-hit trust
In the wake of the worst maternity failings in NHS history, Shrewsbury and Telford Hospital Trust may now also face charges
There’s
been
concern
over
staffing
levelsDebbie
Greenaway
holds her son,
John, who died
during the
Shrewsbury and
Telford scandal,
as revealed in
The Sunday
Times last weekNottingham University Hospitals NHS
Trust has been served with a warning by
the CQC because of concerns that in-
adequate staffing levels and delays in
triage, among other problems, are put-
ting woman and babies at risk. Almost
400 families have contacted an NHS
review of maternity care at the trust that
was launched last year. Between 2010
and 2020 at the trust 34 babies died and
46 infants were left with brain damage.
The families are demanding a full inquiry
similar to that undertaken in Shrews-
bury, saying they have lost confidence in
the local NHS review.
Gary Andrews, whose daughter
Wynter died in 2019 as a result of neglect
by staff, said: “We’ve engaged in the pro-
cess, we’ve given it a chance, but the cur-
rent review is not fit for purpose.”
Jack Hawkins, whose daughter Harriet
was stillborn in 2016 after mistakes by
midwives, added: “The language coming
out of the hospital and the review is not
accepting that there has been a major
problem in Nottingham.” He said an
external review was needed to ensure
that officials “looked at every case”.
The local MPs Alex Norris, Nadia
Whittome and Lilian Greenwood have
backed calls for an inquiry, adding: “We
want the local NHS review of services to
work, but it’s clear that families are not
getting the resolution they need. The
care of mothers and babies in Notting-
ham is still not safe. This has to change.”
An inquiry into baby deaths and
poor care at East Kent Hospitals Uni-
versity NHS Trust is due to report this
year.
Ockenden, who led the Shrews-
bury investigation, said the lessons
from her report “should be learnt
across the wider NHS” and 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”.
The Healthcare Safety Investiga-
tion Branch, which has carried out
independent maternity investigations
for NHS hospitals since 2018, said it hadDetectives have begun an investigation of
the deaths of two babies at the hospital
trust at the centre of the worst maternity
scandal in NHS history.
The babies died in separate incidents
last year at the Shrewsbury and Telford
Hospital NHS Trust, both during their
delivery. One of them was a twin.
The cases were among 600 examined
by West Mercia police alongside an
inquiry by Donna Ockenden, a senior
midwife and manager, into failings at the
trust. Her report revealed last week that
201 babies had died and 94 had suffered
brain damage as a result of avoidable mis-
takes. Nine mothers also died because of
errors in care.
Detectives are working with prosecu-
tors to determine whether charges
should be brought over the two deaths
last year, after years of warnings that
maternity services were in crisis. West
Mercia police said they were investigat-
ing the trust as an organisation as well as
individuals.
The trust could face a charge of corpo-
rate manslaughter if it is found the way
the hospital organised and managed its
services caused a death that amounted to
a “gross breach” of its duty of care. If
found guilty, the trust would face an
unlimited fine. Individuals charged with
gross negligence manslaughter could
face a prison sentence if convicted.
The Ockenden report revealed that
staff who raised concerns had been
repeatedly silenced, and that patients
had been ignored and in some cases
even blamed for their own death.
Fears are growing that the
unsafe care identified in the report
could be happening in other parts of
the country. Two fifths of maternity units
have been rated as inadequate or needing
improvement for maternity safety by the
Care Quality Commission (CQC), and the
latest data shows that eight out of ten
investigations of maternity incidents in
hospitals across England in the past four
years have resulted in calls for improve-
ments in care.Shaun Lintern Health EditorRhiannon Davies, left, and
Kayleigh Griffiths, who helped
uncover the scandal, embrace
after the report’s releasehospitals. But actually we don’t need new
hospitals; we need new models of care
and new ways of providing care. Staff are
trying to make the models of care from
the 1940s work in the 2020s.”
He warned that the government’s
focus on savings and reducing surgery
waiting lists could “distort people’s
behaviour” and patients needing care in
other areas could suffer.
“There are all these other areas where
care needs to improve. It isn’t just about
elective [planned] care. I think if we focus
just on elective care, we’ll be ignoring a
lot of people who don’t have a stronger
voice but still need care.”
@ShaunLintern
My painful fight to have an ‘unnatural’
birth, News Review, page 19
Matthew Syed, page 23made safety recommendations in 1,
reports: 81 per cent of the cases it has
investigated.
Professor Ted Baker, the outgoing
chief inspector of hospitals for the CQC,
said: “The culture of ‘deny, deflect and
blame’ has been played out in full meas-
ure in Shrewsbury. The current dysfunc-
tional culture stands in the way of
improving safety. It puts staff under enor-
mous pressure, leading to burnout, and it
leaves patients and their families dis-
traught that the system does not listen to
them when they raise justified concerns.”
Baker, who retired from his role last
week after five years, said NHS maternity
services had “held on to the unsafe cul-
ture of blame and recrimination”.
He added: “I have been asking 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. Other
industries do this; why can’t healthcare?
The review of regulations has been
delayed by the pandemic, but I do hope
this will be retained.”
He backed calls for regulation of NHS
managers, which would make them sub-
ject to codes of conduct and liable to
being struck off, like doctors. He said it
would help them resist unsafe demands.
“This is not about punishing managers.
It’s about treating them with respect as
professionals. Leaders need courage to
challenge the prevailing culture.”
Baker said he was frustrated not
enough changes had been made to the
way the NHS was designed. “The model
of care we provide now has not changed
since the NHS was set up [in 1948]. Every-
one wants to build wonderful new