Shropshire baby deaths: What do we know?

Princess Royal Hospital sign
Image caption Shrewsbury and Telford Hospital Trust was placed in special measures

Two troubled hospitals are at the centre of a baby death scandal thought to have the potential to become "one of the biggest crises in maternity care in NHS history".

More than 200 families have come forward amid a review into claims children died or were permanently harmed by care failures at Telford's Princess Royal and Shrewsbury Royal hospitals.

Although not all the cases relate to deaths or serious harm, many are alleging significant errors, according to the BBC's Michael Buchanan.

What has happened so far?

Image copyright Tasha Turner
Image caption Tasha Turner and partner Jacob's baby Esmai died in 2013 at Royal Shrewsbury Hospital

In April 2017, then Health Secretary Jeremy Hunt announced an investigation into a "cluster" of avoidable baby deaths at the Shrewsbury and Telford Hospital NHS Trust, which runs both hospitals.

The review was initially focused on 23 cases in which maternity failings were alleged.

In August 2018, its scope was expanded to look at 40 cases between 1998 and 2017, then later to 100.

As of November 2018, 215 families had come forward, although it was understood not all the cases related to death and serious harm.

According to BBC social affairs correspondent Michael Buchanan, some of the deaths being investigated happened as recently as December 2017.

The trust said it was co-operating fully with the review, which is being led by midwife Donna Ockenden.

How did babies die?

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Media captionJack Burn died hours after being born at Princess Royal Hospital in Telford

Exact details of the cases being looked at by the Ockenden review have not been released, but details of some parents' experiences are in the public domain.

Failures to properly monitor foetal heart rates and delays in deliveries were found to have contributed in more than one case.

Out of seven avoidable deaths between September 2014 to May 2016, failure to properly monitor heart rates was found to be a contributory factor in five, the BBC discovered.

One such case involved Kelly Jones, whose twin girls were stillborn at Royal Shrewsbury in 2014.

She said she was ignored by staff despite repeatedly telling them she felt pain during pregnancy.

The trust admitted her daughters' deaths from oxygen starvation to the brain had been contributed to by "delay in recognising deterioration in the foetal heart traces and the missed opportunities for earlier delivery".

A further report found the 2009 death of Kate Stanton-Davies at six hours old could also have been avoided after warnings of potential complications were missed.

The trust said it had "failed to meet the high standards we set for all of our patients".

It has since paid out millions of pounds in compensation to families of babies born with brain injuries.

One firm handling claims said it was "repeatedly seeing the same errors - failures in relation to heart trace monitoring and realising the baby is in distress, delays in taking women for an emergency caesarean and issues with the wrong use of forceps".

What are the other problems?

As well as the midwife-led, independent review into alleged maternity errors, the trust in charge of both hospitals has also been placed in special measures.

It has faced criticism from the Care Quality Commission, whose inspectors assess the standard of services provided by a hospital.

In October, inspectors were so alarmed by what they saw on the trust's maternity and emergency wards in Shropshire that they ordered bosses to submit weekly status reports.

A few weeks later, the trust received its third CQC warning in four months - highlighting staffing concerns in certain critical care and emergency areas.

Two days after that, the trust was placed in special measures - meaning it was no longer trusted to run itself alone.

Unusually, the decision was taken by health service bosses before the CQC had made a recommendation to do so.

NHS Improvement said it had identified a number of "challenges" which could threaten patient safety, including governance, staffing, urgent and maternity care and whistle-blowing issues.

The CQC said it would have been likely to recommend special measures, as it believed the trust would be unable to improve "without external support".

Chief executive Simon Wright said the trust welcomed the move and the "extra support" it would bring to ensure necessary improvements could be made.

What's the next step?

Image caption It is not known when Donna Ockenden's review will be published

The trust will receive "enhanced support", including additional funding, while in special measures, NHS Improvement said.

The trust is usually re-inspected by the CQC within 12 months of going into special measures, but this can be sooner if there are "significant concerns about quality", or if there is "enough evidence of good progress", the watchdog said.

If inspectors feel a trust has made enough progress, they will recommend it is taken out of special measures.

Where there has been insufficient progress, the CQC will consult with NHS Improvement to decide whether further action is needed.

It is not known when the Donna Ockenden review will publish its findings.

Her website still carries an appeal for "anyone who feels they have... significant questions that remain unanswered" about their care at the trust to get in touch.

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