5 June 2018
The Shrewsbury and Telford Hospital NHS Trust (SaTH) has written to families who raised concerns and queries about their care in its maternity service, going back some 19 years. These concerns were raised following the announcement last year that the Secretary of State for Health had asked NHS Improvement (NHSI) to undertake an independent review.
The independent review is looking at historic investigations into a number of cases which relate to newborn, infant and maternal deaths raised in a family’s letter to the Secretary of State for Health in December 2016.
The announcement of this investigation in April 2017, led to 16 families coming forward with questions about their care, and an additional 24 cases were put forward for review by the independent midwife leading the NHSI review. These cases cover a 19-year period. During this period, we have seen over 91,000 babies born at SaTH.
The Trust established a Clinical Review Group to examine those cases which were not included in the Secretary of State’s review to ensure a robust process and complete transparency. The Group undertook a preliminary review of those cases where there had already been a complaint or serious incident and assessed the clinical care of the remaining patients using a structured process adapted from the Royal College of Physicians. This tool helped to identify if there was any potential learning from the care provided at the time.
The Group consisted of clinical leaders from neonatology, obstetrics, paediatrics and midwifery and to ensure openness, transparency and for further assurance representatives from Telford and Wrekin, and Shropshire Clinical Commissioning Groups. The clinicians involved in the review process were not involved in the original care that those families received.
Of the 40 cases, five cases were unidentifiable from the information provided so no further action could be taken, and of the 35 identifiable cases which date from 1998; the Trust has:
- Written to 19 families to say there were no signs of any failures in care and has offered to discuss the case further with the family should they wish.
- Written to four families to say there is potential for further learning and to seek permission for the case to be reviewed by independent clinical experts to ensure all of the learning is established.
- Written to eight families recognising a review had been undertaken previously and, on that basis, it was recommended these cases undergo further examination and to seek permission for the case to be reviewed by independent clinical experts.
The cases of four families were reviewed and there were no signs of any failures in care. These families were unaware their cases had been put forward for review by the independent midwife leading the NHS Improvement review and will not be contacted individually by the Trust. The Clinical Review Group recommended this approach which was supported by the Trust Board as it was felt contacting these families after such a length of time and potential changes to family circumstances may cause these families further grief or anguish.
Over the coming weeks, the Trust will liaise with the families it has written to and for cases where it has received permission it expects to review the associated independent expert reports this winter.
Jo Banks, Women and Children’s Care Group Director at the Trust said: “We are determined to approach all such cases in an open, transparent way and to learn from these reviews. We are committed to making improvements rapidly and will share our learning from these cases later this year.”