42 dead babies and a culture of arrogance and cover-up that scars the NHS

Published by The Daily Mail (21st November, 2019)

The horror stories could hardly be more disturbing. Dozens of babies dying, scores more with avoidable brain damage, and clinical malpractice that went unchecked for years despite clear warning signs, as well as complaints and official probes.

The grotesque failings at Shrewsbury and Telford Hospital Trust are the largest maternity scandal in the 71-year history of the NHS.

The details are chilling. More than 600 cases are still being examined, but already we know 42 babies died, along with three pregnant mothers, while at least 50 were left with serious disabilities after being deprived of oxygen during birth.

These figures, revealed in a leaked internal report, will undoubtedly climb as investigations continue into the ‘toxic’ systemic failures that turned the joyful human experience of giving birth into a time of dark suffering and grief for too many families.

The distressing details even surpass the Morecambe Bay scandal that was, until now, the NHS’s biggest maternity failure, with the avoidable deaths of 11 babies and one mother in a Cumbria hospital between 2004 and 2013.

In the latest case, staff made basic errors, with disastrous consequences, such as failing to realise that labour was going wrong, not adequately monitoring heartbeats, and ignoring infections that might have been easily treated.

We must accept, of course, that in a hard-pressed service relying on thousands of human beings performing challenging work in difficult situations, there will always be mistakes. It is a tribute to NHS staff that they do not happen more often.

But what is profoundly depressing is to see exposed in such stark terms again the culture of arrogance and cover-up that scars the NHS — especially at a time when sparring politicians are lining up to profess glib adoration of this sacred institution.

Dead babies were labelled with wrong names and even callously referred to as ‘it’, bereaved families were told their cases were one-offs, mistakes were not shared to prevent more deaths, and defensive staff were disrespectful to distraught parents.

One father managed to gain feedback on his daughter’s death only after bumping into an NHS staff member in a supermarket. Another family, beside themselves with grief, were told they would have to leave the hospital if they did not ‘keep the noise down’.

Perhaps the cruellest detail in the report is to learn that a baby’s body was allowed to decompose in an NHS hospital over several weeks into such a state that the family were unable to see their child to bid a final goodbye before burial.

The incidents expose not just medical failure, but a shocking attitude of inhumanity. How could any NHS professional be so crass as to tell a devastated mother who has just lost her baby not to worry as she can become pregnant again soon?

Such contemptuous errors were then compounded by the inept nature of the official responses when alarm bells began to ring. And, once again, as in previous NHS scandals, full details emerged only after traumatised families fought for the truth.

People such as Rhiannon Davies and Richard Stanton, who lost their baby in 2009 after staff failed to flag up that Rhiannon’s pregnancy was high-risk. First came a battle for an inquest, which confirmed avoidable death, and then a fight to force the Trust to re-examine the case.

After the review found systemic failures and that staff had retrospectively altered medical notes, the pair joined with another grieving couple and finally persuaded former Health Secretary Jeremy Hunt to order an independent inquiry two years ago.

Yet, shockingly, there had already been other investigations. One, by the official regulator in 2007, was guilty of what was politely termed ‘misplaced optimism’. 

Another, by the Royal College of Obstetricians and Gynaecologists, was inadequate — which is unsurprising when a probe into patient safety involves minimal discussion with actual patients.

It is beyond comprehension that any health body could believe it is effectively carrying out a review if it does not discuss services in depth with users. Yet such arrogance is symbolic of corrosive and all-too-pervasive attitudes that can flourish in the health service — as glimpsed in previous NHS scandals.

Remember heroic cafe owner Julie Bailey from Stafford, whose elderly mother entered a local hospital for a routine operation and ended up dead in degrading circumstances?

Along with other families and brave whistleblowers, Julie fought closed ranks of medical staff, as well as local hostility, to uncover the deaths through ‘unacceptable’ neglect or maltreatment of up to 1,200 patients in two hospitals run by the Mid Staffordshire NHS Trust — deaths later found to be down to persistent failings at every level.

Then there was Sara Ryan. She exposed the needless death of her son Connor, a teenager with autism and epilepsy who drowned in a bath in the ‘care’ of Southern Health, a leading mental health trust run by an award-winning chief executive.

The Trust claimed he died of natural causes, but eventually it was found guilty of serious neglect and it emerged that another patient had also drowned seven years earlier. Her efforts sparked a national review into wider issues of avoidable deaths of people with learning disabilities.

Even the story of what happened at Morecambe Bay emerged thanks to the strength of a shattered family who turned the spotlight on a cavalier medical culture at Furness General Hospital.

Joshua Titcombe was only nine days old when he died in 2008. Yet his grieving parents suffered years of official denial in their determination to expose what was dubbed a ‘lethal mix’ of failures in a local system scarred by incompetence, cover-up and staff collusion. Distressed citizens should not have to endure obfuscation, vilification and traumatic legal battles to ensure others do not suffer the tragedies that have befallen their families.

These scandals are all linked by a culture that too often ignores patients and families, even in the most disturbing circumstances.

I have seen this myself as the father of a daughter with disabilities and serious health issues. Many NHS staff are superb — but some are blasé, others dismissive or downright rude. Meanwhile, bureaucratic inertia grinds down those seeking to impose improvements and instigate reform.

Look at the failure to free 2,250 people with autism and learning disabilities locked up in mental health units, despite widespread acceptance that their lives would be improved and safer in their own homes with cheaper and more effective community support.

Or the frightening number of deaths and incidents of abuse in inadequate, privately run psychiatric units.

Again and again, we see how the system, the managers, the medical professionals and their representative bodies resist change, crush whistleblowers and ignore patients and families.

Yet where is the motor for improvement when timid politicians on all sides never dare criticise the NHS? Instead they just proffer platitudes, bicker over spending and joust over statistics while far more serious questions are swept aside.

The harsh truth is that our health service, far from being the envy of the world, performs poorly when compared with similar nations on many key patient outcomes — including not just cancers and strokes, but mortality rates for infants in their first month of life.

Yes, more funding is crucial — although a study last year by four respected think-tanks found Britain spends almost the average for rich nations.

And we must urgently sort out the shameful collapse of social care.

But money is far from the only issue. At the core of any effective health system lies decency, honesty and humanity towards patients — and, sadly, all too often there seems to be a hole in the heart of our hallowed NHS.

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