14 November 2018
The Shrewsbury and Telford Hospital NHS Trust (SaTH) strives to give the safest and kindest care to all mums and babies we look after. Most of the time birth is a normal, natural and joyous event. Very occasionally a birth does not go well. Sometimes that is unavoidable – a baby may have conditions that are untreatable – but on rare occasions something goes wrong which, if things were done differently, there may have been a different outcome.
As a Trust, SaTH has committed to making sure we learn from every incident where we know we could have done things better.
The trauma of a bereavement or harm to a baby or mother can last a lifetime for the family and their loved ones. Our staff understand that and feel pain when things don’t turn out in the way that everyone hopes.
We are working closely with families who have contacted us following the announcement of an NHS Improvement-led enquiry into historic maternity issues. Families have approached the Trust and the separate NHSI-led review with a range of questions and issues and we want any family that has a concern or a question to come forward so that we can help them.
In April 2017, the Secretary of State for Health requested NHS Improvement undertake the independent review of investigations the hospital trust had already undertaken into a number of historic cases. The cases were named in a letter to the Secretary of State for Health in December 2016 and included new-born, infant and maternal deaths at the Trust. Those 23 cases that will be reviewed, subject to family consent, are those named in the letter in December 2016.
The announcement of the NHSI-commissioned investigation led to the Trust being made aware of other ‘legacy’ families who had concerns and queries about their care.
Further publicity has resulted in a number of other families approaching the Trust with enquiries about their maternity experience.
Separate from the NHSI-commissioned investigation, the Trust is or has discussed issues with 91 families who have come forward to discuss their experience over a 44 year period from 1973 to 2017. Of these 36 relate to questions about deaths and 22 to cases of permanent harm. During this period there have been around 198,000 births at the Trust’s hospitals in Shropshire and Telford & Wrekin.
Not all of these cases relate to the quality of care provided. Some families have contacted the trust for general reassurance and information. Others have questions they would like answering.
It is clear in some cases that the issue relates to the grieving process and an opportunity for remembrance. The care group is addressing all enquiries with compassion and care for the families irrespective of time passed.
Any case of death and harm has already been investigated by the trust and the results discussed with the families concerned.
However, where a family has come forward with fresh concerns or questions the trust has reviewed the notes of the care the mother and baby received. Where there is any suggestion of fresh material or evidence, the trust has appointed external reviewers to examine the case notes.
Legacy Cases
There are 31 cases which the Trust has been made aware of following the announcement of the Secretary of State review. These cover a 19-year period from 1998 to 2017.
The 31 cases fall into the following categories:
| Category | Number |
|---|---|
| Birth Experience | 4 |
| Death | 14 (under the following, nationally recognised definitions): Intrauterine Early neonatal Late neonatal Infant Paediatric |
| Gynaecological complication | 1 |
| Non-permanent harm (eg admission to neonatal unit/post-partum haemorrhage) | 4 |
| Permanent harm (eg developmental delay/physical disability) | 5 |
| No harm (eg questions regarding delivery of care) | 3 |
12 of these cases are being reviewed by external experts as outlined above.
In 19 cases, no evidence was found of any omissions of care. Three families had further questions and we have been working with those families to answer their questions. This has so far resulted in one case being closed with the family.
Post Legacy Enquiries
Publicity around the Secretary of State review and legacy review has led to other families contacting the Trust with enquiries. The director for the Women and Children’s Care Group is personally contacting each family.
There have so far been 60 enquiries covering a 43-year period from 1973 to 2016. The enquiries fall into the following categories:
| Category | Number |
|---|---|
| Birth Experience | 13 |
| Death | 22 (under the following, nationally recognised definitions): Intrauterine Early neonatal Infant Intrapartum Maternal |
| Non-permanent harm (eg admission to neonatal unit/post-partum haemorrhage) | 5 |
| Permanent harm (eg developmental delay/physical disability) | 17 |
| No harm (eg questions regarding delivery of care) | 3 |
Of the 60 enquiries received, 8 have so far been closed with the families’ questions answered.
Around 4,500 women give birth at The Shrewsbury and Telford Hospital NHS Trust each year, which is around 198,000 births between 1973 and 2017.
Combining the legacy cases and post-legacy enquiries, SaTH has been approached regarding:
- 36 deaths
- 22 issues of permanent harm
These cover a 44-year period from 1973 to 2017, with 10 pre-dating 1998.
We continue to assist families by supporting them to find resolution to their questions and concerns.