Hayley Matthews is still waiting for an apology for the death of her son Jack Burn in 2015. He died 11 hours after he was born at Telford’s Princess Royal hospital from a group B streptococcus infection, pneumonia and a heart attack.
An inquest found that failings in care by Shrewsbury and Telford hospital NHS trust contributed to his death. “My son has been gone five years and I’ve had loads of meetings with them but I’ve never had a ‘sorry’ from them,” Matthews told the Guardian.
Matthews is not alone. On Tuesday it was announced that serious concerns about the trust’s maternity services had been raised in another 496 families’ cases, bringing the total under independent investigation to 1,862.
The trust’s chief executive, Louise Barnett, issued a general apology to the community for failings in its maternity services. She said: “There is no doubt that this continues to be a difficult and painful experience for the many families and I am truly sorry for their distress.”
While she waits for a personal apology, Matthews fears the scandal could be even bigger than the trust is letting on. She said: “I still think they are hiding things. They didn’t tell me I had pre-eclampsia. And they tried telling me that my son’s heart rate was normal when it was sky high, to the point when he had a heart attack inside me. And they got his medicine wrong. It makes me wonder how many other families they did it with.”
She added: “It means more to me than anything at the minute – for them to apologise and to correct things so it doesn’t happen to anyone else.”
Rhiannon Davies’s daughter Kate Stanton-Davies died under the trust’s care soon after she was born in 2009. The health service ombudsman for England found that the death was avoidable and that there were serious failings in her care. It ordered that the trust apologise to Kate’s family.
In 2015 when Davies met the then health secretary, Jeremy Hunt, and the trust’s then chief executive, Peter Herring, Hunt asked Herring why he had not apologised until he had been ordered to do so. Davies recalls him saying: “I thought someone else had.”
A year later, Davies and the family of Pippa Griffiths, who died in 2016, raised their cases and those of 21 others in a letter to Hunt. This led to the establishment of an independent review in 2017 by the maternity specialist Donna Ockenden.
Hundreds more cases have since emerged. There are now so many now that Ockenden has drawn a line under the 1,862 cases she and her team have identified so far. Ockenden now wants to prioritise recommendations for the trust so that it urgently improves patient safety.
In the meantime, the details of the most egregious cases, including the deaths of Jack Burn and Kate Stanton-Davies, have been passed to the police. In a letter to the families last month, West Mercia police confirmed they were investigating whether there was enough evidence for a criminal case either against the trust or any individual members of staff.
Davies has been encouraged by the thorough way Ockenden has approached the review. And she is determined that she should not be hampered from getting at the truth. “I see it as very personal to my family because without my daughter’s case the Ockenden review wouldn’t exist. Anyone who tries to muck it up will face my full wrath. It is a massive opportunity for learning.”
The trust now accepts that its standards of care fell short. But until very recently it has been fiercely defensive of its record and reluctant to accept criticism.
A report by the Royal College of Obstetricians and Gynaecologist (RCOG) in 2018 said: “Neonatal and perinatal mortality rates will not improve until areas of poor/substandard care are addressed.”
A follow-up review published on Tuesday by NHS Improvement sharply criticised how the trust handled the RCOG’s criticism. It suggested it was more worried about public and media reaction to the RCOG report than about patient safety. “We are concerned by the apparent lack of ongoing scrutiny of the actions designed to address RCOG’s recommendations, particularly given that they referenced patient safety,” the review read.
The trust also delayed publishing the critical report until it could offer assurances that improvements had been made. The follow-up review said: “It would have been more transparent to publish sooner.” The review found a “culture of defensiveness, denial and/or lack of openness that existed at the time in maternity services.”
The parents of Kate Stanton-Davies and Pippa Griffiths, called for the current board to be replaced. In a letter to the chief inspector of hospitals, also released on Tuesday, they said: “We believe the board is complicit in the active prevention of change for the benefit of patient safety and therefore needs to be immediately sacked. How many times will it need to be told before it listens?”
