How Many More Babies Must Die Before Lessons Are Learned?

Kate Stanton Davies, Jenson Barnett, Ella and Lola Greene, Sophiya Hotchkis, Oliver Smale. Jack Burn, Kye Hall, Graham Scott Holmes-Smith, Ivy Morris & Pippa Griffiths.

These are the babies, that we know of, who died needlessly in maternity services in Shropshire.

In February, Secretary of State Jeremy Hunt ordered a review into a cluster of 15 baby deaths, and three mothers, at the Shropshire Telford and Wrekin hospital Trust (SaTH). At least eleven baby deaths between September 2014 and May 2016 have already been ruled by the coroner as avoidable. The tragic, heart breaking, needless loss of little lives before they’ve even begun.

When the medical director responsible for patient safety at the hospital trust was asked to respond, he said, ‘When I look at the perinatal mortality rate at our trust compared to the rest of the NHS, we are at an equivalent level to the rest of the country”.

Hiding behind national averages, when the coroner rules that babies have died avoidable deaths on your watch, is an egregious affront to grieving families. Yet Dr Borman, along with the CEO, Simon Wright, remain secure in their jobs. For her part in this unholy scandal, the head of wifery at the time has been rewarded with a promotion.

There are some striking similarities in the culture that led to the avoidable baby deaths in Shropshire and the Mid Staffordshire scandal. Causal factors, as identified in The Francis report, were:

• A board that was concentrating on cutting costs rather than patient safety
• A Senior Management Team that stopped investigating patient concerns robustly, which meant that patient care was effectively downgraded, and
• The creation of a culture where staff felt unable to raise concerns about clinical safety for fear they would either be ignored or victimised.

In the wake of Kate Stanton Davis’ death in 2009, her parents, Rhiannon and Richard, were faced with the further indignity of a cover up. Amid their trauma and grief, they had to fight  to have Kate’s death investigated properly. On Thursday, at the first hospital board meeting since the BBC broke the story of an investigation into a further cluster of baby deaths in 2014 and 2015, the board hid behind a cloak of secrecy. Despite it being an agenda item, the board refused to comment.

I asked the non-executive directors, as the conscience of the organisation, if they would intervene and hold the medical director and CEO to account for their failings. This was met with blanket silence. The board also refused to answer a question asked on behalf of Kate’s parents, who did not attend in person. The question was, could the subsequent baby deaths have been avoided, had their complaint been investigated properly?

Tory under funding, pay caps and removal of midwifery bursaries have contributed to a midwifery crisis nationally in this country. In 2014, Cathy Warwick, RCM chief executive warned, “Our maternity services are overworked, understaffed, underfunded and struggling to meet the demands being placed on them. This is deeply worrying for the quality of care women are receiving, and the safety of services." She said safety was at risk because services were operating beyond their capacity. "The Government is responsible for this and it is they who are letting down women, babies and their families”.

 In October 2016 she warned that investment in midwifery services from the government 'remains inadequate to provide the quality of care that women deserve'. The RCM carried out a survey of members in which, only 9% of respondents felt that the government valued midwifery.

Tory cuts cost lives. There has never been a more important time to fight for our NHS & there’s no more powerful a place to take that fight than the ballot box. That’s why I’ll be voting Labour on June 8^th.

See video below of my speech at a recent NHS rally.