Scandal-hit NHS trust at centre of baby deaths review receives another warning

An NHS trust at the centre of a maternity scandal has received its fourth warning in eight months over the safety of its services, it has been revealed.

Shrewsbury and Telford Hospital Trust was told it failed to meet national standards following an inspection into its maternity units and emergency departments in April.

The Care Quality Commission (CQC) slapped the trust with a section 31 warning – meaning it could face closure if changes aren’t made.

It’s the latest development following a string of scandals at the beleaguered trust, which runs Telford’s Princess Royal Hospital and the Royal Shrewsbury Hospital.

Shrewsbury and Telford Hospital Trust has been given its fourth formal warning in eight months over the safety of its services. The trust runs Telford’s Princess Royal Hospital and the Royal Shrewsbury Hospital (pictured)

Two of the previous warnings were also formal section 31 notices.

The most recent warning stemmed from concerns over a lack of staff in the trust’s emergency departments – particularly a lack of paediatric staff.

Edwin Borman, medical director for SATH, said: ‘We were not able to see all of our patients in 15 minutes, in line with national performance targets, and some of our patients left before we could start treatment.

‘We have alerted our GP colleagues of any children who left our EDs before treatment, which was the main area of concern for the CQC.’

WHEN WERE THE FOUR WARNINGS ISSUED?

Shrewsbury and Telford Hospital Trust has received four warnings about the safety of its services in eight months.

They were issued by multiple watchdogs in quick succession.

Similar issues were raised in the cases.

May 2019

The most recent came this month, following an inspection of its maternity wards and emergency units.

The Care Quality Commission (CQC) issued a section 31 warning over concerns of a lack of staff in the trust’s emergency departments – particularly a lack of paediatric workers.

CQC could not go into details because it said it needs to give the trust an opportunity to appeal.

But SATH’s medical director conceded that staff weren’t able to see all emergency patients within the 15-minute national guideline.

October 2018

CQC issued three urgent warnings following an inspection into the trust’s emergency services and maternity units in August.

Two section 31 warnings were issued on maternity services and emergency departments.

And a less-severe section 29A warning was issued for its medical care, critical care and urgent and emergency care services.

The trust was told it had until March to address the host of failings.

SATH’s third warning came in October, when the trust was told it had until March to address a lack of paediatric staff within its emergency department, risk assessments for malnutrition and pressure ulcers not being carried out – as well as a lack of consultant and nursing staff within the intensive therapy unit.

The development comes as an independent review was launched into more than 250 cases of poor maternity care at SATH over the last two decades.

Former health secretary Jeremy Hunt launched the review in April 2017 into 23 baby deaths in the hospital.

But after the review was announced, dozens more families came forward.

In September 2018 the West Midlands Quality Review Service warned SATH about its lack of trained staff in paediatric resuscitation.

Its report noted that paediatric staff were only available ‘9am to 10pm Monday to Friday and 12 noon to 10pm on Saturdays and Sundays’.

It added: ‘A registered healthcare professional with level one Royal College of Paediatrics and Child Health competences was not always available at Royal Shrewsbury Hospital after 10pm when paediatric staff were not on site.

‘Reviewers considered that a child could arrive and need resuscitation after 10pm and that a member of staff with appropriate competences to lead the resuscitation might not be available.’

Nigel Lee, chief operating officer at SATH, said: ‘In Shropshire throughout April we have seen huge increases in emergency demand with over 20 per cent more attendances and 30 per cent more ambulances at our emergency departments.

‘Our staff are working incredibly hard to manage this demand whilst we await our new recruits who will start with us in June.

‘The trust has approved spending over £1 million on additional staffing this year for our EDs and as these new nurses and doctors start, we can be confident the service will continue to improve and meet all of our obligations.’

Amanda Stanford, deputy chief inspector of hospitals at CQC, said: ‘CQC inspected the maternity and ED services at Shrewsbury and Telford Hospitals Trust in April.

‘As a result we took further urgent action with regard to ED care, including paediatrics. We are unable to give further details at this time but will report on our findings shortly. All CQC’s action is open to appeal. We are monitoring the trust closely and liaising with NHSI and NHSE.’

What was Shrewsbury and Telford Hospital Trust’s baby scandal?

In April 2017, then-Health Minister Jeremy Hunt launched an independent review in the hospital after it was revealed seven babies had died needlessly.

But after the review was announced, dozens more families came forward, prompting a probe into 23 baby deaths and 250 cases of poor maternity care at SATH over the last two decades.

It emerged that a failure to properly monitor heart rates played a contributory factor in five deaths, while another two were found to be suspicious.

Most of the deaths occurred between 2014 and 2016, while one of the avoidable deaths took place as early as 2013.

Inquests or legal action against the Trust found that seven of the deaths were avoidable.

An investigation by the Trust found that two babies died from oxygen starvation to the brain ‘contributed to by delay in recognising deterioration in the foetal heart traces and the missed opportunities for earlier delivery’.

A monitor used in hospitals, called a cardiotocograph, can give an indication of how the foetal heart rate is responding to the stress caused by the mother’s contractions. It has been in use for decades but errors are still being made.

The Shrewsbury and Telford Hospital NHS Trust delivers about 4,700 babies each year.