It was with sadness that I recently read that dozens of babies and 3 mothers have died on the wards of a single hospital within The Shrewsbury and Telford Hospitals Trust and that an investigation has revealed that dozens of deaths could have been avoided. The report reveals that more than 50 children, in addition to those that sadly died, have suffered permanent brain damage after being deprived of oxygen during birth and a further 47 other cases have involved substandard care. A further 600 cases are now being examined which will likely add to the reported figures of avoidable deaths and avoidable injury. Tragically this is not the first time I have read such reports. I am reminded of the scandal that hit the Cumbria Furness General Hospital between 2013 and 2014 which involved 11 babies and 1 mother dying avoidable deaths. One of the striking features to come out of the latest report about the Shrewsbury Hospital is that not only were clinical errors made but they were then repeated and there was substandard investigation of these errors. Without proper investigation lessons will not be learnt. It is being suggested in the report that regulators of the hospital were aware of problems as long ago as 2007 and yet deaths continued and avoidable injury arose as late as 2017.
This report comes at a time when a further report has been released dealing with the early notification of incidents involving maternity units which meet what is known as the ‘Each Baby Counts’ criteria which essentially deals with brain damaged babies. This report has found that only 77% of Hospital Trusts throughout England and Wales have notified families concerned that an incident has occurred even though they have reported it internally. In 2014 a duty of candour was brought in to all NHS bodies requiring Clinicians to advise those affected, including families, of untoward incidents as a matter of course and carrying with it disciplinary consequences for failure to do so. Yet here we are in 2019, some 5 years after the duty was imposed upon Trusts, with almost a quarter not reporting to families that incidents involving brain damaged babies have arisen. These two recent reports illustrate that within parts of the NHS there is a continuing failure to actively engage with a learning process to reduce such tragic incidents. We act for many families affected by such tragedy and sadly see similar incidents being repeated time and time again.