Whose fault is it?
Written by | Yan Xiaoliu
Source | "Medical Community" public account
Richard Stanton will never forget that on the day of his first fatherhood, his child died in his arms.
"After giving birth, I took a group photo of the mother and daughter, and then helped my wife to wash up. Suddenly, the midwife came up to me and told me that the child was no longer breathing. They did 30 minutes of CPR, which had no effect. Then, with the child in my arms, I boarded a rescue helicopter and headed to the nearest neonatal intensive care unit. The midwife did not follow the machine. They handed me a note saying the receiving hospital would understand it. ”
"It's too late. Kate Stanton-Davies was born less than 6 hours after leaving us. None of my wives saw the last glance. Richard recalled.
Kate Stanton-Davies with her mom. /Wales on Line
Kate Jr.'s healthcare facility is affiliated with the NHS Foundation Trust consortium Shrewsbury and Telford Hospital NHS Trust (SaTH). The NHS, known as the UK National Health Service, provides free health care for all and is regarded as one of the UK's "national identities".
On March 30, local time, a 5-year-long, 250-page SaTH special investigation report was released.
Its content shows that between 2000 and 2019, SaTH repeatedly failed in its duties. "Due to the lack of effective diagnosis and care, the consortium and its subordinate medical institutions have caused the deaths of at least 9 pregnant women and 201 fetuses and newborns." West Mercia police involved in the investigation said.
Of the 201 poor children, 131 were stillbirths and 70 occurred in the neonatal stage.
The survey also found 29 cases of severe brain injury in newborns and 65 cases of neonatal cerebral palsy, stemming from improper instrumentation and vaginal delivery requirements.
"It's all because the hospital is arrogant, arrogant, understaffed and unsafe patient safety management, and the deliberate pursuit of natural birth rates." The BBC said.
Jeremy Hunt, Britain's former health minister who had ordered an investigation, saw the report and said it was the worst maternity scandal since the creation of the NHS and that "the findings were worse than I thought." ”
Richard Stanton and his wife hold the full text of the report. /PA
The more families involved are looking for each other
After the report was released, SaTH CEO and other senior executives publicly apologized through the media. Richard and his wife, Rhiannon Davies, refused to accept, saying the hospital had never sat down with the families involved and told the truth.
"We sued for 13 years. Initially, we just wanted to know why Kate died. It's that simple. But the more we learned, the more disappointed we became. They sucked. Richard said his wife, Liannon, had no initial plans to give birth at the institution involved. The agency has only midwives and no obstetricians. But the agencies involved were forcefully retained: "We don't have many people here, and you will get better care." ”
Two weeks before giving birth, Lianon felt something was wrong.
"I told the midwife that at least seven or eight times, there was less fetal movement. No one takes it seriously. They insist that I am low-risk and should and can give birth naturally. No doctor is required to give birth. Lianon said.
Little Kate was born, pale, crying and breathing weakly. A few hours later, on March 1, 2009, she passed away.
Richard and Lianon then applied to the local NHS administration for medical malpractice identification, requesting a thorough investigation of the production hospital and SaTH.
In November 2012, the first findings were released, finding that the production hospital and Sathor had committed malfeasance and were responsible for Kate's death. The investigation said Kate Jr.'s death report was "poorly written" and "unreasonable and inaccurate in many places."
The survey also pointed out that hospital staff were "blindly confident" in dealing with pregnancy complications and finding abnormalities during pregnancy and childbirth, and were reluctant to invite high-level experts to participate. There is a tendency between midwives and obstetricians to confront each other, with some midwives refusing to intervene with obstetric consultants.
Midwives testified that they could not get timely and effective help from obstetricians, but they were often questioned by the other party about their ability and professionalism, which made them anxious, depressed and so on.
SaTH has fully denied the allegations.
Richard and Lianon made up their minds to go to the end. They traveled around for their daughter and found that there were medical safety problems in the obstetric departments of many institutions under saTH, and the number of families involved may reach hundreds.
Group photo of families participating in the SaTH special survey. /PA
Among them, Julie Rowlings had a difficult birth. The midwife misuses forceps, causing Julie's child to die 23 hours after birth due to brain damage. The local Coroner's Court held Sath was responsible for the child's death.
When Charlotte Jackson was 37 weeks pregnant, she felt less fetal movement and the amniotic fluid seemed to break. "The hospital said I was just wetting the bed. In November 2018, I gave birth to Jacob and was stillborn. Afterwards, Charlotte's husband hired a lawyer to participate in the investigation. SaTH voluntarily acknowledged its responsibility and agreed to compensate and settle.
The children of Rev Charlotte Cheshire and Kayleigh Griffiths were both infected with group B streptococcus during production. Leif's son Adam was successfully rescued, but left with severe sequelae and a disability. Kelly's child died 31 hours after birth.
According to the World Health Organization, about 15% of pregnant women worldwide (nearly 20 million per year) have group B streptococcus in their vaginas and usually have no symptoms. But it can be transmitted to the fetus through the uterine barrier or to the newborn during childbirth.
Kelly knew nothing about the germs he carried. No one told her that she should be prophylaxised with antibiotics during childbirth or that she should have a caesarean section.
In 2016, Liannon and his wife, Kelly and others jointly launched an investigation application. They took the initiative to "expose" the news to the media and organized a family parade in the hope of promoting the investigation.
The following year, Jeremy Hunt, britain's former health secretary, followed the incident. He ordered an independent investigation into SaTH obstetric services, led by Senior Midwife Donna Ockenden. According to the previously approved documents, the investigation involved 24 medical accidents, including stillbirths, premature neonatal deaths, and serious brain damage.
The bereavement of Mr. and Mrs. Liannon, Mr. and Mrs. Kelly and others are all involved.
Rev Charlotte Cheshire and son Adam. /PA
"For more than 20 years, no one has spoken out"
The result was unbearable for Donna to see. "A lot of facts have proved that SaTH has not been investigated, learned, and improved in the past 20 years."
She led the team in a review of 1,592 birth incidents in 1,486 households producing in SaTH and its subsidiaries between 2000 and 2019.
A number of problems were exposed:
First, the one-sided pursuit of spontaneous childbirth, even if the mother has medical reasons and should have a caesarean section, still insists on lobbying for natural childbirth.
For more than a decade, SaTH's caesarean section rate has been 8%-12% lower than the UK average. This data has long been used as a "benchmark". This has led to a bad "primordial" atmosphere in SatH.
Exchanging natural childbirth for KPIs has a long history in the UK. Until 2017, the Royal Association of Midwives officially announced that it would suspend the "natural childbirth campaign" to allow pregnant women to choose the mode of childbirth. Earlier this year, the NHS required hospitals to stop using caesarean section rates as a performance indicator.
Second, perinatal monitoring is insufficient, and fetal/neonatal heart rate monitoring omissions occur many times, which seriously affects medical safety.
Third, there is a serious shortage of manpower and a lack of effective training, resulting in inadequate care, resulting in a large number of maternal and newborn injuries;
For example, there were 65 cases of childbirth that resulted in a fracture of the skull or cerebral palsy of the newborn due to the misuse of forceps during labour. 29 infants suffered brain injuries due to lack of oxygen at birth. Of the 498 stillbirths, about a quarter were found to be due to inadequate care. Two-thirds of newborns born with hypoxia are due to the mother's lack of proper care before and during delivery.
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Fourth, hospital management did not investigate and reflect in a timely manner, "they lightly dismissed the application for a maternal death investigation and blamed the baby's death on the mother and her family." Donna said.
In a difficult birth in 2011, the husband was told "because your wife was too fat to have a difficult birth." Because of the fatness, it is difficult for midwives to hear the baby's heartbeat and miss the best rescue time. ”
"We have multiple obstetric check-ups here. No one has ever been warned of a body size problem, nor has it ever been said that it can lead to improper fetal heartbeat monitoring. ”
In addition, a 2002 report of the deceased stated: "Maternity is responsible for her death. She was unable to express her feelings accurately and did not report many symptoms in time. ”
Donna pointed out that in 2011-2019, 40% of stillbirths and 43% of neonatal deaths were "unaccounted for", which shows that SaTH has not done internal investigations at all. In the incidents reviewed, nearly half of stillbirths and more than a third of newborn deaths were reported "very poorly".
There was a case of neonatal death that struck Donna's heart. "The medical staff writes the nursing requirements on the note sticker and sticks them in a conspicuous position, which means to publicize them and strengthen the care of newborns. As a result, the cleaners removed it as garbage. ”
Fifth, local health authorities are derelict in their duties.
Donna said the NHS had conducted an investigation into SatH in 2013. It was concluded that its medical services were safe. The survey also affirmed SaTH's "ultra-high" natural birth rate and significantly below-average caesarean section rate, saying it was a positive outcome.
"The NHS has been slow to pay attention to these issues for the past 20 years. No obstetricians and midwives across the UK have an opinion on this. SaTH has not been tracked down by a third-party independent agency. Donna said there was a need for systemic changes across the NHS to ensure that care provided to families was always professional and safe.
Donna Ockenden at the launch of the investigative report. /PA
The police launched a "manslaughter" investigation
On the afternoon of the day the investigation report was released, British Health Secretary Javid publicly apologized in the House of Commons.
He said the report painted a tragic and poignant picture of the repeated failures of maternity care over the past 20 years. "It's caused unimaginable trauma to a lot of people, not moments of joy and happiness." I would like to apologize to all the families who have suffered. We will act quickly, and in the future, hopefully no family will suffer the same pain again. ”
The Independent quoted Richard as saying, "This may be a watershed for fertility safety in the UK." ”
The Daily Mail believes the investigation should not stop there.
The newspaper said that in 2017, Richard obtained the second investigation into the cause of Kate Jr.'s death, again judging Sathor to be derelict in his duties. This time, SaTH was mistaken. The following year, the midwife involved was dismissed and his license revoked.
But none of the SaTH executives have been investigated.
In the years that followed, "fertility scandals" continued about the agency. During this period, many high-level executives jumped to other institutions, and even some people entered private medical institutions, and their annual salaries increased from hundreds of thousands to millions.
In 2020, Ben Reid, a 67-year-old accountant and chairman of the hospital's board of directors, left. He acknowledged that SaTH had sent a delegation to London to persuade the investigative team to write a more positive appendix. The Daily Mail pointed out that the above-mentioned investigation report was published 1 year later than originally planned.
At present, the Police of Western Mesia are investigating whether the aforementioned "fertility scandal" is suspected of criminal offenses and whether there is manslaughter. "The report is finally out and the investigation is likely to intensify. The police finally have evidence to arrest people. Richard told the Daily Mail.
Source:
1.Police are probing brutal mother-blaming NHS trust where 'bullying' midwives and doctors pushed a culture of natural birth which killed 201 babies and 9 mothers - while dozens of infants were needlessly left with brain damage. The Daily Mail
2.Two midwives struck off... and bosses walked into lucrative new posts: No-one in charge at maternity scandal NHS trust is named and shamed in devastating report after families accused them of being 'rewarded for failure'. The Daily Mail
3.Shrewsbury maternity scandal: Repeated failures led to deaths. BBC
4.Shrewsbury maternity scandal: ‘Unimaginable trauma’ caused, says Javid as report details avoidable baby deaths. The Independent
5.Police examine 600 cases after damning NHS baby deaths report. The Guardian
6.The heartbreaking death of a Welsh couple's baby that led to the worst maternity scandal in the history of the NHS being uncovered. Wales on Line
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