201 babies and nine mothers could have survived if an NHS trust had provided better care in the UK’s biggest maternity scandal at Shrewsbury and Telford Hospital NHS trust. Police are examining more than 600 cases linked to the scandal.
In a letter to the Secretary of State for Health and Social Care from Donna Ockenden, Chair of the Independent Maternity Review, the latter wrote, “I publish the final report of the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust, at a time when the NHS continues to face significant challenges arising from the coronavirus pandemic.”
In her letter, Ockenden acknowledged that the NHS staff – including maternity teams who have worked throughout this pandemic – are exhausted. “We have seen so many frontline NHS staff go above and beyond the call of duty to support and care for their patients in these truly extraordinary times. Our NHS is rightly held in high regard by so many for the lives it saves and the care it provides.
“However, this final report of the Independent Maternity Review of maternity services at the Shrewsbury and Telford Hospital NHS Trust is about an NHS maternity service that failed. It failed to investigate, failed to learn and failed to improve, and therefore often failed to safeguard mothers and their babies at one of the most important times in their lives,” she wrote.
Her letter also threw the spotlight on the fact that there have been significant pressures in maternity services in the recruitment and retention of midwives and obstetricians.
Madhuri Bedi, Bereavement Support Services Officer, Sands (Stillbirth and neonatal death charity) spoke to Asian Voice about women her organisation has helped in order to navigate challenges with the NHS.
At Sands, she hears from bereaved parents who tell them they didn’t feel they were listened to when they tried to raise concerns about their or their baby’s care during pregnancy or birth.
Bedi said, “Removing barriers to accessing care and improving communication between healthcare professionals and parents is especially important when caring for Asian women or those from other ethnic minorities, particularly those for whom English is not their first language. There is a complex mix of risk factors that can contribute to the death of a baby, but we know that Asian and Asian British babies are 1.6x more likely to be stillborn than White babies.”
Parents need to be given culturally appropriate information
According to the Bereavement Officer, parents need to be given culturally appropriate information in their preferred language, about what they can do to keep themselves and their baby safe during pregnancy, and to have access to interpreting services when they use healthcare services (online, over the phone, and in-person).
Commenting on the latest news of Shrewsbury and Telford Hospital NHS Trust, Madhuri said, “The recent report from Donna Ockenden into Maternity Services at Shrewsbury and Telford Hospital NHS Trust (SaTH) highlighted the need to really listen to parents so that opportunities to take action that could save babies’ and mothers’ lives are not missed. Crucially, hospitals need enough staff, resources and support to do this effectively. Trusts which are struggling must be identified earlier and offered support so that babies and mothers are kept safe and well. ”
“We have also heard from parents and healthcare professionals that the Covid-19 pandemic had an impact on both maternity and bereavement care. Families, parents and mothers shared key concerns with Sands about having fewer appointments, attending appointments and scans alone, particularly for those pregnant after loss, receiving bad news alone, and PPE affecting the staff’s ability to give compassionate care,” she added.
Can NHS be more patient-friendly?
Discussing the core issue that needs to be addressed in order to make the NHS more patient-friendly, Bedi told Asian Voice, “Listening to parents is key and we must ensure that bereaved parents' voices are heard by decision-makers in the NHS and government so that their experiences help improve safety in maternity and neonatal care. When a baby does die, parents must have the opportunity to feed their thoughts into the review of their baby's death, and to ask the questions that are important to them.”
She further mentioned that for healthcare professionals it can feel difficult to approach parents at an acutely distressing time and to raise sensitive issues. “We have developed resources, both within Sands and in collaboration with the Perinatal Mortality Review Tool group, to support anyone engaging parents in a review or investigation process,” Bedi told the newsweekly.
Repeated maternity failings
Meanwhile repeated maternity failings and serious concerns about the safety of mothers and babies in Sheffield have come to light following the UK’s biggest maternity scandal at Shrewsbury and Telford Hospital NHS trust.
The Care Quality Commission (CQC) found Sheffield teaching hospitals NHS foundation trust, one of the largest NHS trusts in England, had failed to make the required improvements to services when it visited in October and November, despite receiving previous warnings from the watchdog, The Guardian reported.
When it came to the medical staff at the Sheffield trust, the “service did not have enough medical staff with the right qualifications, skills, and experience to keep women and babies safe from avoidable harm and to provide the right care and treatment”, the report said.
Inspectors have reportedly found that staff were not interpreting, classifying or escalating measures of a baby’s heart rate properly, an issue that was raised in Ockenden’s review.
It also “highlighted that the service continued to lack urgency and pace in implementing actions and recommendations to mitigate these risks, therefore exposing patients to risk of harm”.
The report added: “We were informed by staff that there were often difficulties requesting additional assistance when women’s health was deteriorating. Staff told us that there were occasions when they would ‘bleep’ for medical assistance on more than one occasion before assistance arrived. We were also told on multiple occasions that there were instances where an emergency call buzzer would be pulled after receiving no response to multiple bleep calls.”
NHS hits a 25-year low
It is an alarming yet not quite unprecedented fact that public satisfaction with the NHS hits a 25-year low. The latest British Social Attitudes survey showed overall satisfaction with the NHS at 36 per cent, down 17 percentage points from two years ago.
In an Op-Ed in Financial Times, Camilla Cavendish wrote, “The NHS has been our national religion, partly because it treats us without payment in our hour of need. But the idea that it’s “free” has sometimes made us too grateful and allowed the system to close ranks. The NHS is not actually free: we pay for it through our taxes. This should give patients the right to ask questions, and not to struggle for years, as the Stanton-Davies and Griffiths families courageously did in Shrewsbury, to find out why their babies had died.”
She also empathised that “there is a culture of fear in parts of the NHS which helps neither patients nor the dedicated staff who are sick of working with bullying colleagues and box-ticking managers.”
While the NHS has been recognised for its world-beating excellence in some places, it does have some appalling management failures in others.
The NHS has been our national religion, partly because it treats us without payment in our hour of need. But the idea that it’s “free” has sometimes made us too grateful and allowed the system to close ranks. The NHS is not actually free: we pay for it through our taxes. This should give patients the right to ask questions, and not to struggle for years, FT reported.
Strange fairy tale theory
The Conservative party has been criticised for its strange fairy tale theory that the NHS needs a revamp and most of its problems are due to lack of funding. As has been the fashion for years, they point the finger at lazy doctors, as medical staff go into the profession in the hope of an easy life and not to improve the lives of their patients. The vast majority of people (94 per cent) still believe in the founding principle of the NHS: free when you need it. Almost as many (80 per cent) have identified a lack of NHS funding as the core reason for their dissatisfaction. The public wants the NHS to continue and they know it is failing due to this government’s decision to let it. Something has changed; the government can no longer hide their role in letting the NHS fail. Everyone has experienced how strained NHS staff are when they turn up at an A&E ward, or knows a nurse or junior doctor who is trying to do their best while they face longer days and a squeeze on resources, the New Statesman reported.
Birth givers speak
UK based Kamaljit Uppal told the BBC Panorama documentary ‘Maternity Scandal: Fighting For Truth’, she was refused to undergo a Caesarean section at the Royal Shrewsbury Hospital and told to deliver naturally – even though her son was in the feet-first breech position, which made it much riskier to attempt a vaginal birth.
In a heartwrenching account, Uppal told that after 18 hours of labour, he was eventually delivered by emergency Caesarean. Uppal was still groggy from her general anaesthetic when, in her words, her son was ‘plonked’ on her and she was told he had died.
In 2020, then 31 weeks pregnant Shrimoyee Chakravarty told Asian Voice “My experience with the NHS in the last seven months has been awful. I had never been given a growth chart of my baby and I was only told about this last week when I was 29 weeks pregnant. When someone asked where the growth chart was, I replied oh, I’ve never been given one. Then I was given a growth chart saying the baby should have been monitored weeks ago.
“Even when you go to the midwife's office, they seem like 18th-century offices with old computers, no printers. They still use an old school heartbeat monitor to check the heartbeat of the baby. It’s just ridiculous,” she added.
When she was 14 weeks pregnant, she suddenly started bleeding. “I went to the hospital at 10 pm at night, because of bureaucratic nonsense, they kept pushing me from one ward to the other. They kept saying that we’ll only see you at fourteen weeks and I was 13 weeks 4 days pregnant. They pushed me around for two hours till I had to literally fight to be seen by a doctor. I said I’m not leaving till you tell me if the baby is alive or not. For me, the whole experience with the NHS has been pretty traumatic, to say the least,” Shrimoyee explained.
Chetna Mistry, 42, told the BBC she is a 'prisoner' to endometriosis — a condition where tissue similar to the lining of the womb starts to grow in other places, such as the ovaries and fallopian tubes. Mistry has reportedly been left infertile and in need of a hysterectomy — a surgical procedure to remove the womb. “She was referred to a specialist in June 2020 but still does not have a date for her operation,” she told Daily Mail.
Grim messages for leaders
Not just patients, the staff at Liverpool's biggest NHS organisation sent a grim message to senior leaders - who issued an apology over their "deeply unsatisfactory" experiences. In the 2021 annual NHS Staff Survey, only 50% of respondents agreed that the trust was fair in awarding promotions regardless of ethnic background, religion, gender, sexual orientation, disability or age, down from 53.7% the previous year.
It is also important to address the fact that the appointment system at the NHS is also fundamentally flawed. If one needs an appointment right now, they may get it after a month, or in the case of Chetna Mistry, years! This also means that appointment slots where patients don’t turn up or are missed, end up being a horrific disadvantage for those who need it more than others. While community pharmacists are ready to share the burden with NHS, it is still a long road ahead. In between getting an appointment and a prescription and then the actual medicine from a pharmacist, sometimes time, life and faith are lost.
Not every person has come out victorious in the pandemic. With job losses, Long Covid woes and more emotional turmoil, the spending capacity amid the rising cost of living have also altered the way patients would approach health. Not everyone will be able to afford private health care if the NHS doesn’t fundamentally fix its alleged broken foundation.
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Gynaecology waiting lists jumped 60% over the pandemic
570,000 women are now waiting for appointments, tests, scans and operations.
NHS figures show the number of women forced to wait more than a year for routine treatment is now almost 380 times higher than it was before Covid.
Data shows 6.1million were waiting for routine treatment by the end of January
Nearly 24,000 were waiting more than 2 years, a 9-fold increase from April 2021
