Much media interest was generated following the announcement by Health Secretary Jeremy Hunt that a “cluster” of baby deaths at Shrewsbury Hospital would be the subject of an NHS England investigation.
Coroner’s Inquests have identified failings in the care provided by the Trust to mothers and babies in the course of labour and delivery. Seven separate instances were investigated in the period between September 2014 and May 2016 alone. Two further deaths have been described as “suspicious” but the parents have been denied a formal investigation. In at least four cases, a failure to properly monitor the baby’s heart rate in the womb (CTG trace) has been identified as the cause of the problem.
Sadly such stillbirths (babies who have died before or in the process of delivery) and neonatal deaths (babies who survive but die shortly after birth) are not uncommon. The Shrewsbury & Telford NHS Trust have stated that their death rates are consistent with the national average, which may well be the case. The fact that the public at large and the media are not generally aware of the incidence of such tragic losses is the most likely explanation for the current focus on the issue, rather than any particular failing unique to this hospital trust.
The question then arises as to whether being consistent with the national mortality rate is acceptable, or whether Mr Hunt should be investigating stillbirths and neonatal deaths across the NHS more widely.
Problems with monitoring babies’ heart rates are nothing new, they are at the core of the majority of investigations into the severe brain injuries suffered by some babies in the course of delivery, leading to lifelong disabilities such as cerebral palsy in some cases, and death in others.
Some maternity units have worked hard at learning from their mistakes, implementing staff training to reduce the possibility of avoidable errors. It is noticeable that throughout the reports on the Shrewsbury incidents, the failings are clearly identified as “avoidable errors”. These are not simply mistakes which anyone might reasonably make in the conduct of their duties but errors which should not be made in any circumstances. That the outcome of such errors is a tragic loss is heart rending for the families involved. That in the majority of cases, those families then have to battle to discover the truth surrounding the loss of their child only serves to exacerbate the situation.
The effect on parents and families must be at the centre of these investigations but it is perhaps noteworthy that in many cases, stillbirths and neonatal deaths could fall below the fixed legal costs level being considered by the government in clinical negligence cases, making it impossible for parents to pursue their enquiries with the support of lawyers experienced in extracting answers from the NHS. Suggestions that stillbirths and neonatal deaths might be excluded from such a scheme must be adopted if Mr Hunt has a genuine desire to see improvements brought about in the care offered to mothers and babies in our hospitals.
At Clarke Willmott LLP we have considerable experience of dealing with stillbirth, neonatal death and birth injuries of all types and supporting parents through investigations. If you would like to talk to a lawyer with a specialist knowledge of such issues call on 0800 316 8892 or e-mail one of the team.