Call for resignations at top of scandal-hit hospital trust as number of cases rockets to 1,862
A total of 1,862 cases of alleged poor maternity care are under investigation in Shropshire, it has been confirmed, as the full scale of the scandal became clear.
And just days after ITV Central highlighted delays in releasing the findings of an official investigation into allegations of a cover up by senior board members at the Shrewsbury & Telford Hospital Trust, NHS bosses have finally published a report which backs up families’ complaints.
It reveals that senior Trust bosses appeared more concerned with mitigating the impact of criticisms to avoid negative media reports than they were with transparency or making the required improvements.
Families have now called for those involved to resign.
An extraordinary, and particularly unpleasant, day for those involved in what is now indisputably the biggest maternity scandal in NHS history - and one of, if not the, biggest scandal across all kinds of care.
It’s complicated, as these official investigations and reviews always are, but it makes for some shocking reading.
Here’s what you need to know.
The campaign for justice
The campaign for justice began in 2009, when Rhiannon Davies and Richard Stanton demanded answers over the death of their newborn daughter Kate, who died just hours after being born.
It grew pace when, in 2016, they joined forces with another bereaved family, Kayleigh and Colin Griffiths, who lost their daughter Pippa.
Together, from media reports and anecdotal evidence, they gathered a dossier of 23 families who had been affected by poor care at the Trust and presented it to government ministers. It was this which led to then-Health Secretary Jeremy Hunt ordering the ongoing independent review, led by Donna Ockenden, in 2017.
Now, the review is dealing with a staggering 80 times that original number.
And there are questions over how much those at the top of the Trust knew.
The controversial RCOG review
In 2017, with the Ockenden review now hanging over their heads, bosses in Shropshire commissioned a separate review by the Royal College of Obstetricians and Gynaecologists (RCOG).
But they didn’t like what RCOG found, and the findings were not published until July 2018, accompanied by a largely-positive addendum detailing the “improvements” the Trust claimed had been made.
Chairman of the board, Ben Reid, admitted at a public meeting last year that this had been a deliberate delay as Trust bosses tried to “soften” the criticisms of the report.
The investigation
ITV Central exclusively revealed in January that NHS Improvement had launched an investigation into this behaviour, following complaints from families accusing the Trust of a “cover up”.
Several weeks after this investigation was concluded, the report was finally published this morning - and it makes for some shocking reading.
We now know that senior members of the board tried to persuade RCOG to alter the report. NHS Improvement (NHSI) found that then-chief executive, Simon Wright, “initially would not accept” it, and asked for a ‘progress review meeting’ where seven Trust representatives told RCOG about the improvements they claimed had been made.
“Our view is that the primary purpose of the follow up exercise from the trust’s perspective was to mitigate the perceived adverse impact of publishing the initial report,” NHSI states.
“The overall result was a document that gave the impression that issues in the maternity service had been largely resolved, when in fact there was significant further work to do.”
Upon reading the findings, Kayleigh Griffiths told ITV Central she found it “absolutely shocking.”
Despite the limited evidence from that meeting - which did not involve actually visiting the Trust again to corroborate the claims - RCOG published a largely positive addendum, which the Trust then published as the opening statement at the front of the main report.
“It is important to acknowledge that the trust was not obligated to commission the RCOG review but chose to do so and committed from the start to publish the results, knowing that this would open itself up to further scrutiny,” NHSI adds.
“However, when the outcome was less favourable than hoped for, the primary Trust focus seemed to shift towards the perceived public reaction to the report, rather than getting the right internal assurance and scrutiny to ensure the improvement of services.”
Reaction from families
They’re shocked, and appalled.
Richard Stanton has repeatedly called for the resignation of Mr Reid, who he says is “not fit” to continue in the post.
Furthermore, he has questioned why an additional 496 cases have only recently been handed over to the Ockenden review; with the team writing to the families affected this week.
“Where are these cases coming from? The records have clearly been there this whole time,” he said.
“Every single one of those 1,862 cases is a person, a family, left devastated by the poor care they’ve received at the hands of this Trust.
“Why has it been left to families to fight for years upon years to get answers?”
He also received a personal apology from Mr Reid back in November, after repeated attempts to talk over him and other families, and ignore his questions at past meetings.
“The way he has behaved is unacceptable,” he said.
What does Ben Reid say?
Mr Reid has issued a statement via the Trust, in which he makes no reference to the call for his resignation - but says he has "learned a valuable lesson".
He acknowledges that scrutiny of the original RCOG report would have been improved "if we had decided not to wait for the addendum to the report before placing it before the Board and the Quality and Safety Committee."
He adds: “Action plans were being produced within the Trust but, without the oversight of the full governance process, that clearly wasn’t a robust enough response.
“We, as a Trust, and I personally, have learnt a valuable lesson as to how we handle such reports in the future. I consider it my responsibility to take these lessons forward and ensure they are applied across the organisation.”
However, calls for further comment to address the criticisms of the families have been refused by the Trust.
Does he have the backing of others involved?
We don't know. The Trust has refused to comment on whether the new chief executive, Louise Barnett, supports him continuing in the post.
Similarly, the Department of Health has refused to say whether Health Secretary Matt Hancock - who is directly responsible for holding the chairman of the board to account - will be taking any action to address the findings of the NHSI report, nor whether he supports Mr Reid staying in post.
What have the Trust said?
Ms Barnett, only started in the role in February.
She today published an open letter to the people of Shropshire, stating: "I know that our standards of care have fallen short for many families and I apologise deeply for this."
She added: "There is no doubt that this continues to be a difficult and painful experience for many families and I am truly sorry for their distress. We should have provided far better care for these families at what was one of the most important times in their lives and we have let them down.
"An apology is not enough.
"What needs to be seen is evidence of real improvement at the Trust. This is why we are committed to listening to families, our community, and working with Donna Ockenden’s Review to ensure lessons are learned and we have a service which the community and our patients can trust."
The open letter in full
"I know that you, the communities of Shropshire, Telford & Wrekin and mid Wales care deeply about your local hospitals and the care we provide. All of us experience important life events in hospitals, from the birth of a loved one, to life-changing surgery or treatment in an emergency. You have a right to expect the very best care every time you use our services. However, if things do go wrong, it is the role of the Trust and our staff to learn from any failings, so that we can provide answers to families and patients and improve our care now and in the future.You will be aware that our Maternity Services have been under the spotlight for some time. I know that our standards of care have fallen short for many families and I apologise deeply for this. An independent review, led by experienced midwife, Donna Ockenden, is looking into cases involving families from our communities. Today, we know that the total number of families whose cases are being reviewed is 1,862. I recognise that this will be concerning, both for those families and everyone in our communities, who depend on us for their care. The review is being taken very seriously by our staff too, who are committed to providing our patients with the highest standards of care and making the necessary further improvements to our Maternity Services.There is no doubt that this continues to be a difficult and painful experience for many families and I am truly sorry for their distress. We should have provided far better care for these families at what was one of the most important times in their lives and we have let them down.An apology is not enough. What needs to be seen is evidence of real improvement at the Trust. This is why we are committed to listening to families, our community, and working with Donna Ockenden’s Review to ensure lessons are learned and we have a service which the community and our patients can trust.We have made some progress in improving the standards of care for mothers and babies and the Care Quality Commission (CQC) now rates our Maternity Services as ‘Good’ across three of the five standards (Caring, Effective and Responsive). However, we recognise that we have further to go.One of the things we have learned is that we must be better at listening to everyone who uses our services. We will work harder at this and create more opportunities for families to tell us about their experiences, allowing us to make positive, clear and tangible improvements, based on what we learn. Our opportunity to listen and learn should not be confined to the families involved in the Ockenden Review. Any family not included in the review can come to us at any time to share their experiences or raise any concerns. You can contact us by emailing sath.maternitycare@nhs.net or by calling the Patient Advice and Liaison Service on 01952 641222, extension 4382.We will continue to work openly with Donna and her team to help families get the answers they need and in turn we will make the necessary improvements. In the meantime I want to reassure you that we are working hard to deliver the high quality Maternity Services that the people in our communities rightly deserve.Yours faithfully,
Louise Barnett