Maria Lally Grazia 19th April 2022. Picture Rhiannon, Richard and their baby Kate 2009
“‘In the final two weeks of my pregnancy, in February 2009, she went from being a super-active baby to one who stopped moving…Rhiannon was told she had a ‘lazy baby”! Kate died at 6 hours old.
“After a long fight, in 2016 the trust finally accepted responsibility for Kate’s death. ‘Richard and I thought, ‘That’s it, we’re done,’ recalls Rhiannon. ‘They’ve learned their lesson. This will never happen again. Two months later Pippa died.’
Pippa Griffiths was born in 2016 and struggled to feed, but when her mother Kayleigh spoke to midwives she was told not to worry, even when Pippa coughed up brown liquid. Despite several calls about Pippa’s breathing the night after her birth, she died the following day at just 31 hours old. The trust said they would carry out an internal investigation with no parental input necessary, but Kayleigh, an NHS auditor at another trust, sensed something was amiss and emailed Rhiannon.
The Ockenden Report later uncovered avoidable errors in both cases, along with ‘evidence of poor investigation, and ‘a lack of transparency and dialogue with families.’
‘It is heartbreaking that this report only came about because of the determination of the families,’ says the Royal College of Midwives (RCM) chief executive, Gill Walton. ‘We owe them a debt I fear can never be repaid. The review has identified workforce shortages as being a threat to safety. The RCM has been highlighting this for over a decade, calling on three successive Health Secretaries to invest not only in recruitment but retention of midwives.
‘This review must be a turning point for all those working in maternity services. We all have a responsibility to speak up and speak out about poor behaviours and poor care in our workplaces. I’m asking midwives, maternity support workers, obstetricians and anyone working in maternity services to look around them and ask themselves, is the care being provided where you work safe? If it’s not, I need you to have the courage to speak up. This has to stop.’
‘We only spoke to 109 members of maternity staff, ‘ says Ockenden. ‘That’s a tiny number when you consider our review took place over a 20-year period. Some even withdrew their statements for fear of being identified. The report details cliques on the labour ward’ and ‘little gangs’ that would ‘make your life hell’ if you spoke out.’
Carley McGee, one of 23 families in the report, gave birth to daughter in March 2010. Keeley’s lips and eyes kept turning blue, a sign of pneumonia, but midwives repeatedly told Carley not to worry. The next day, a senior and a trainee midwife visited the new family at home. ‘Keeley was still turning blue, and when the trainee midwife unbuttoned her babygro she said she felt cold and seemed floppy, but the senior midwife dismissed her and they left,’ Carley told Grazia. A few hours later, Carley’s mother insisted Keeley be taken to hospital. ‘But she died on the way. She was barely a day old,’ says Carley.
‘At the inquest, the senior midwife claimed I had Keeley dressed in shorts and T-shirts, and she had to tell me to warm her up. The trainee then got up and said Keeley was dressed properly, and that she’d tried to tell the senior midwife something was wrong after they left the house. The senior midwife fled the room crying at this point. The trainee was so brave to speak out, but the senior midwife is still working. I can’t put into words the anger I felt that day.'”
I wonder what happened to the that trainee – was she bullied out of the profession for speaking out?
“‘I hope the women will now feel heard when they speak up,’ says Ockenden. ‘Our families asked for two things – to understand why their baby died, with many being told half truths or untruths. And to know it wouldn’t happen again.’
The Ockenden Report, the result of a five-year investigation into the maternity care at Shrewsbury and Telford NHS Trust over a 20-year period, found more than 200 babies and nine mothers would have survived if not for the failings of the trust. The report found a reluctance to perform Caesarean sections despite risks to mother and baby (the trust’s C-section rate was eight to 12% lower than the national average), bullying and cliquey culture among midwives, underfunding and understaffing, and a reluctance to investigate patient concerns. In some cases mothers were lied to about why their babies had died. Two similar reviews are not underway in Nottingham and East Kent…
“Ockenden, ‘A generation of women were silenced by the system, but that won’t happen again.'”
I wish I shared her optimism! From everything I’ve so far read about bullying in the NHS, the scale is terrifyingly dangerous. If those working in the NHS are too afraid of the consequences of speaking up about bad or dangerous practice it will be patients who bear the result. My aunt Chris joined the NHS as a nurse soon after it’s inception, she left the NHS in the 1980s because she didn’t like the way the NHS was being run – her professional standards were being compromised. The example she gave me was bed sores – a sign of inadequate nursing or an inadequate number of nurses.
#NHSscandals #Ockenden #FundWomensHealthcare