Incompetence, conspiracy – and how our culture of NHS worship is costing lives
Published by The Daily Mail (25th August, 2020)
Today Harry Richford should be a bundle of energy, full of curiosity and mischief like any other toddler approaching his third birthday as he simultaneously delights and drains his parents.
Instead his mother and father mourn a little boy who lived for just seven difficult days. Their agonies are intensified since they grieve a son who, according to an inquest this year, died a ‘wholly avoidable’ death.
‘The poet John Donne wrote “Any man’s death diminishes me”. If that is true, how much more are we all diminished by the death of a newborn baby?’ asked the coroner Christopher Sutton-Mattocks movingly, before delivering his grim ruling of neglect.
Harry died due to basic failures of health care. The inquest heard from experts who testified that he would have survived with ‘competent hands’ in delivery, then could have been saved by ‘resuscitation . . . of an appropriate standard’.
Instead there was a catalogue of errors. An inexperienced locum doctor performed an emergency Caesarean too late, then, after the boy was born silent, pale and ‘floppy’, another doctor delayed resuscitation with fatal consequences.
Yet for two years, East Kent Hospitals University Trust offered no apologies and accepted no responsibility. This bereaved family claim its staff dismissed Harry’s death as ‘expected’ and denied there were any birth complications.
So yet again, traumatised parents had to take on the might of a health bureaucracy closing ranks to cover up mistakes. And yet again, we should give thanks to a grieving family for their courage that exposed deadly wider failings.
They feared East Kent would not refer the case to a coroner. So the boy’s grandfather Derek Richford used freedom of information requests to uncover the fact that just 11 of its 93 stillbirths and newborn fatalities over two years had sparked ‘serious incident’ inquiries.
Then other distraught families stepped forward with similar stories and now the Government has launched an investigation following the deaths of at least 15 babies in potentially avoidable circumstances at East Kent’s two hospitals.
But why does it have to be like this? Why are there so many of these dismal medical blunders followed by egregious cover-ups?
And when will our politicians, health chiefs and that army of well-paid NHS managers finally tackle the arrogant and insidious attitudes that inflict extra pain on families ensnared in such scandals?
Instead they offer hollow apologies and promise to learn lessons before brushing aside fatal flaws in the heart of the health service, until the next disaster emerges.
Of course, any medical service will make mistakes, since they rely on human beings working under great pressure.
I would never wish to demean the efforts of many fine doctors, nurses and other staff — but equally, we cannot ignore the corrosive culture that lurks behind the cuddly facade of our sanctified NHS.
‘Since Harry died we have found the trust have done everything in their power to avoid scrutiny,’ said Derek Richford. ‘I still can’t fully decide if this was gross incompetence or a conspiracy to cover failings.’
It is hard to know which is worse. Yet this tragedy is far from unique. Police recently began probing maternity concerns at Shrewsbury and Telford Hospital NHS Trust in what may spiral into the worst patient safety scandal in modern British history.
We know so far that 1,200 cases are being investigated. And a leaked report into ‘toxic’ systemic failures last year revealed 42 babies and three mothers have died over almost four decades, with 50 more children left brain damaged.
It showed again some of the attitudes that scar the NHS: bereaved people told their cases were unique; mistakes hidden; dead babies identified by wrong names; investigations that ignored views of patients’ families.
It seems this horrifying story is bigger than the Morecambe Bay scandal, previously the NHS’s most devastating maternity failure with the avoidable deaths of 11 babies and one mother in a Cumbria hospital between 2004 and 2013.
That saga emerged only after a grieving family fought official obfuscation. The father, who lost his nine-day-old baby, told me when they tried to raise the alarm, the system recoiled against them as if they were the cause of the problem.
This exposes a fundamental problem at the NHS’s heart: a misguided belief that the system revolves around its staff, not the patients who gratefully seek help and treatment (and pay its soaring costs through their taxes).
Indeed, in two more scandals — the deaths of elderly people in squalor at two mid-Staffordshire hospitals and the drowning of a teenage boy in his bath that exposed wider care failings for people with learning disabilities — the whistleblowing relatives were subjected to grotesque abuse and smears.
These cases show such issues extend far beyond maternity wards. Last month saw an official report into three separate outrages involving two drugs that left children with serious disabilities and pelvic mesh implants that caused terrible pain for thousands of women.
This inquiry was the legacy of another long struggle for justice. Baroness Cumberlege, its author, confessed she was shocked by the scale of the suffering and that so much of it was avoidable, compounded by systemic failures.
But in all probability her words about a ‘disjointed’ system that lacks leadership and fails to listen properly to patients will simply join all those other reports into previous health scandals making similar points that gather dust in health department vaults.
Earlier this year we had a brutal report into the hideous case of Ian Paterson, a breast surgeon who butchered and wounded hundreds of patients over 14 years before being stopped from performing often-needless operations.
Women were let down ‘at every level’ and ‘treated with disdain’ when complaining after ‘multiple individual and organisational failures’ did not stop this monstrous man.
Their voices were heard only after they found sympathetic lawyers. ‘By that stage many found their exhaustion was too great and their sense of rejection so complete that they scarcely had the emotional or physical strength to fight any further,’ said the report.
This is the dark side of the NHS — and these same flaws crop up again and again. Note how often the victims are women, the elderly, or patients with learning disabilities, their voices crushed in a system that remains too hierarchical and bigoted against such groups.
Such fears were reinforced last week by a review into 50 deaths of people with learning disabilities in the pandemic that indicated ‘prejudicial attitudes’ made them far less likely to receive full treatment in an intensive-care unit.
So what can be done to improve patient safety? One thing is certain: we should stop putting this public service on a pedestal since our NHS worship only fosters arrogance, calcifies poor management and prevents politicians from trying to improve services.
We must ensure genuine support for whistleblowers, insist on full disclosure of all blunders and rapidly reform a compensation system that encourages cover-ups and drags out pain over years of legal battling.
Admitting mistakes shows strength, not weakness.
Studies indicate one in ten patients is harmed during health care. So will we keep stumbling from one horror story to another in our sacred health system — or finally take resolute action to stop babies such as Harry suffering needless deaths?