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Shrewsbury and Telford Hospital NHS Trust is to be subject to an NHS Improvement review ordered by Jeremy Hunt following a number of baby deaths under its care.
7 avoidable deaths have been identified at the trust within a 2-year timeframe, with sufficient concern raised about the standard of care provision and subsequent investigation (or lack of it) that the Health Secretary has seen fit to investigate further, and to ask the trust to contact the families concerned.
In total, 9 “suspicious” deaths have been identified at the trust between September 2014 and May 2016, and whilst 7 were deemed “avoidable” in coroner reports, the remaining 2 are yet to be fully investigated according to the families. An additional avoidable death was also recorded in 2013. The frequency of avoidable deaths recorded at the trust has led many to question whether care standards have slipped to the extent where medical negligence can be identified, which could mean the families concerned may be eligible to make birth injury claims.
In five of the cases failures on the part of medical staff to accurately monitor the baby’s heart rate through the use of a cardiotocograph (CTG) were identified as contributory factors. Whilst the technology is well-established and has been used in hospitals for decades, medical staff occasionally make errors – such as mistaking the mother’s heart rate for the baby’s or vice versa – which can expose both to the risk of a misdiagnosis or delayed diagnosis of life-threatening conditions. Avoiding these mistakes is a key part of providing care to the standards we expect from the NHS.
A June 2016 inquest into the death of Kyle Hall also found errors on the part of hospital staff contributed to his death when they failed to classify his mother’s pregnancy as “high risk” on two separate occasions and to adequately monitor his foetal heart rate at critical opportunities prior to birth. Kyle died at just 4 days old due to oxygen deprivation in the brain during pregnancy and subsequent brain damage. His death is not just tragic in its own right, but particularly pertinent to any considering pursuing cerebral palsy claims at the hospital. No such condition was identified in his case, but oxygen deprivation during pregnancy is one of the main causes of cerebral palsy.
The trust’s services were also severely criticised in 2016 following a report on another baby’s death in 2009. On that occasion an investigation commissioned by NHS England found a “lack of a safety culture”, and that no staff had been held accountable for the death of Kate Stanton-Davies, with no lessons learned from the tragedy. Another analysis has since rated Shrewsbury and Telford as one of the worst in the country in regards to learning from failures, describing a “poor reporting culture”.
There have been instances too where there may have been grounds for forceps delivery claims or caesarean section claims. In reference to Oliver Smale’s death in 2015 a coroner testified that his death could have been avoided if he was delivered at an earlier stage by caesarean section, and back in 2013 a coroner similarly concluded that Jenson Christopher Barnett’s death could have been avoided if delivery had been attempted through the use of forceps or a caesarean section.
These delivery methods carry risks in their own right however, and where force is applied without due care during child delivery erbs palsy claims could be made in response to nerve and / or brain injury inflicted on the child. Clearly steps have been taken to investigate these incidents which should continue to enable education and therefore to avoid and minimise them in the future.