​The hidden review of maternity services at Pennine Acute Hospitals NHS Trust

Like many of us, I became aware of the Pennine Acute Hospitals NHS Trust internal review of maternity services through the Manchester Evening News this month.

The report was prepared in June 2016. It took the MEN three months to extract the report from the Trust following a Freedom of Information Request.

It would not have come to the public’s attention at all had it not been for the bravery of a whistle-blower at the Trust and the tenacity of the MEN journalists.

All this despite the Duty of Candour introduced in 2015 as a direct response to the Francis Report into Mid Staffordshire NHS Foundation Trust.

The Francis report recommended that a statutory duty of candour be introduced for health and care providers. Robert Francis QC defined openness, transparency and candour as follows:

• Openness – enabling concerns and complaints to be raised freely without fear and questions asked to be answered.
• Transparency – allowing information about the truth about performance and outcomes to be shared with staff, patients, the public and regulators.
• Candour – any patient harmed by the provision of a healthcare service is informed of the fact and an appropriate remedy offered, regardless of whether a complaint has been made or a question asked about it.

Now that we have access to the internal report from the Pennine Trust, what does it tell us?

The Trust had more legal claims against it than any other between 2010 and 2015. Specific cases referred to include the death of a mother due to a catastrophic haemorrhage because the staff did not recognise that she was deteriorating and of the shocking incident involving a baby who was too premature to be resuscitated and was left to die in the sluice.

The reviewers looked back at cases over the last three years and found that there were common themes: basic vital signs were not being checked; Early Warning Scores were scored incorrectly, giving false reassurance and delaying treatment; there was poor documentation; and pathology results were not followed up. There were concerns about the leadership in the maternity units; bullying; a poor skills mix due to experienced staff retiring; and junior staff being overruled. A toxic mix which is not conducive to sharing knowledge and expertise.

Whilst I am disturbed by the contents of the report, I am sad to say that I am not surprised. North Manchester General Hospital and The Royal Oldham Hospital have been high on the list of hospitals involved in the clinical negligence cases I deal with over many years and the issues highlighted in the review arise frequently. The cases which result in legal claims are those where serious injury or death has occurred as a result of the failings, but there are many events which are classed as ‘near misses’ which may not be brought to light by a legal case and yet families are still badly affected by the events.

We know that staff are working under incredible pressure and more staff are needed, but the review confirms that there are repeated errors which are not directly due to low staffing levels. Part of the report focusses on the financial cost of claims to the NHS and, not unexpectedly, the claims involving birth injuries such as cerebral palsy represent the highest cost. This is because of the level of care and support a child requires over their lifetime as a result of the brain injury they have suffered due to hypoxia during their birth.

A key factor in preventing these cases is proper interpretation of the CTG trace which monitors the baby’s heart rate during labour. Training on this equipment is vital, but with 34% of the Trust’s Obstetric Consultants being locum and many of the midwifery staff being agency, how can families be confident that training is kept up to date. Charities such as Baby Lifeline provide training to help maternity and neonatal units, but Trusts have to ensure sufficient staffing and funds to enable staff to attend.

More fundamentally, a culture of openness needs to permeate each organisation from the top down. There needs to be commitment to transparency at the highest level. How can standards improve unless we learn from one another?

Gill Edwards is a partner and clinical negligence solicitor with PotterReesDolan. Should you have any queries about clinical negligence issues or indeed any other aspect of this article and wish to speak to Gill or any other member of the team please contact us on 0161 237 5888.