NHS regulators were “missing in action” when it came to tackling serious problems at Shrewsbury & Telford Hospital Trust, MPs say - as campaigners question why it was left up to bereaved parents to take action.
As the dust settles from a damning report from the ongoing independent review into services at the Trust, campaigners have demanded to know why red flags - including a 10% higher death rate on the maternity unit than other comparable trusts between 2013 and 2016 - did not lead to action sooner.
"Who knew about this - and why did they keep quiet?" Gill George, from local campaign group Shropshire Defend the NHS, said.
The first report was published last week, and analysed the first 250 of 1,862 cases of concern at the trust, largely dated between 2000 and 2019.
At the very centre of that timeframe, in 2009, Richard Stanton and Rhiannon Davies suffered the loss of their daughter Kate at just six hours old.
Ever since, they have been on the frontline of the fight for answers.
“1,862 is a shocking number. How was that allowed to happen?” Richard said.
“That goes beyond the hospital - it goes to the Clinical Commissioning Group (CCG), who only five year ago were writing to us to tell us this was a safe service to use.
“It goes to the Care Quality Commission (CQC), who five years ago were rating this hospital as good. It goes to NHS England.
“All of these external bodies who are there in place to ensure that healthcare is good and thorough and safe for people to access and use, have got questions to ask about why they didn’t discover these failings themselves sooner.
“Why was it left to bereaved families to do that?”
It was after they teamed up with Kayleigh and Colin Griffiths, who lost their daughter Pippa in 2016, that between them they managed to compile a list of 23 cases which convinced then-Health Secretary Jeremy Hunt to order the review.
And from there, the review ballooned.
Gill George said it was “frightening” to think that without the determination of families like Kate’s and Pippa’s, the problems at the Trust might still be continuing undetected.
“How many deaths does it take to convince an NHS bureaucrat that there’s a problem?” she said.
“How many lives would have been saved of babies and mothers, how much harm, how much lifelong disability, would have been avoided if those people with a responsibility to protect the public had actually done their jobs?
“It’s actually very very frightening because if it can happen in maternity, it can happen across any other service, and if it can happen in Shropshire, it can happen anywhere in England.”
Meanwhile, during a meeting of the government’s Health and Social Care Committee, which is now chaired by Jeremy Hunt, the “deafness of regulators” was criticised by MP Rosie Cooper.
“My question relates to the ‘higher’ deafness - the deafest of regulators, who I would say were missing in action in most of these inquiries,” she said.
“How can you feel confident that we can wake up the regulators - they cost us a lot of money - and make this work for patients?”
Donna Ockenden, who is leading the review, promised that questions surrounding the actions of bodies including the CQC and the CCGs will form part of the wider inquiry, with her full report expected towards the end of next year.
After her initial report was published last week, Shrewsbury & Telford Hospital Trust apologised to the families who had been caught up in the scandal, and promised to take the actions recommended in the report.
ITV Central has asked the CCGs in both Shropshire and Telford & Wrekin for a response to the criticisms, along with NHS England and the CQC - including the question of why it was left to bereaved families to raise the alarm.
In response, a spokesperson on behalf of the CCGs in Shropshire and Telford & Wrekin said: “Our thoughts are with all of the families involved. We welcome the report which we now need to review. In the meantime, we will continue to work with the Trust to further improve maternity services across Shropshire, Telford and Wrekin.”
A statement from the NHS did not address the specific criticisms regarding historic knowledge, but listed a number of actions it has taken within the last year.
A spokesperson said: “NHS Improvement has taken decisive action on behalf of bereaved families and people under the care of Shrewsbury and Telford Maternity services to improve services for mothers, babies and their families including bringing in a new chair, chief executive and chief nurse to lead the organisation, and have established an improvement alliance with a neighbouring trust rated outstanding for leadership.
“But we expect Shrewsbury and Telford Hospitals to deliver further meaningful changes soon or further regulatory action will be taken if needed to ensure services are safe.”
The CQC told us that it had ordered the Trust to make improvements as far back as 2014, including recommending it be put into special measures in 2018.
They said Ms Ockenden's report had highlighted how the Trust has failed to act on concerns raised by the CQC and others, and said: "Ultimately, it is the trust’s responsibility to ensure the safety of the people in its care and to take proactive steps to improve where issues are identified."
Prof Ted Baker, the CQC’s Chief Inspector of Hospitals, added: “The death or injury of a new baby or mother is a devastating tragedy and something that everyone working in the health and care system must do all they can to prevent. “The emerging findings from Donna Ockenden’s review make for difficult reading. Limited oversight of risk, insufficient safety training for staff, poor communication with families, and a lack of robust investigation or learning when errors were made. Sadly, these are all themes that have been identified before, but yet again it has taken the repeated persistence of campaigning families and patients to bring them to the fore.
“The continued national focus on the safety of maternity services is welcome – and we are seeing some positive change. However, the progress made does not yet meet the scale of the challenge."
He said he welcomed the recommendations made in Ms Ockenden's report.