A senior figure in an NHS trust’s maternity unit under investigation over avoidable baby deaths has admitted that some practices in the unit were “hopeless”.
Andrew Tapp, medical director of women and children’s services at Shrewsbury and Telford hospital NHS trust, said in an email to a GP: “I think there are real problems here.” The GP had raised concerns about the maternity’s unit’s communication of test results.
The emails, seen by the Guardian, were sent in May 2016. The GP says his concerns about the safety of patients persist, citing a recent incident he was involved in that could have risked the life of an unborn baby.
The renewed concerns about the unit come as it has emerged that NHS chiefs are now investigating the deaths of 15 babies and three mothers. Several deaths have already been judged to have been avoidable; some were allegedly caused by a failure to correctly monitor babies’ heartbeats or spot infections early.
A team is also reviewing 10 further cases where patients survived but suffered harm.
The GP’s emails express alarm about the maternity unit’s procedures for communicating medical test results, accusing some departments of having a “fax and forget” attitude.
He said that without explanation or context, it was difficult for GPs to understand why particular tests had been ordered, how to interpret the results and how follow up appropriately.
The GP, who has expertise in patient safety, said: “At best these issues are an irritation; at worst, it’s dangerous. There seems to be an inability to change and to learn from mistakes. The safety culture isn’t responsive.
“It has always been thus during the years I’ve been a GP here. The reason why I’m speaking out is because as a GMC-registered doctor I have a duty to speak up about this kind of thing. I believe that patients are at risk and that there’s a lack of effective learning about safety at the trust. My motivation is to protect patients and I’m frustrated that there has been little change over the years.”
A second GP working with the hospital trust shared his fears.“When we have concerns we have to keep asking about them again and again,” he said. “There’s a genuine concern about patients and staff. There are lessons to be learned here.”
The case cited by the first GP was of a vulnerable young pregnant woman who was tested for a group B streptococcus infection. He said there was a significant delay in the maternity unit communicating the positive result to her GP, and that some of the information had been “scribbled” and was unclear.
Any woman with this infection is at risk of passing it to her baby – with potentially life-threatening consequences – unless antibiotics are promptly administered.
Last week an inquest into the death of one-day-old Pippa Griffiths, who contracted the same infection at the same hospital trust, found that she could have survived if she had received better medical care.
A Care Quality Commission report in January 2015 found that the trust required improvement and that while staff were caring, they needed more feedback about incidents to learn from their mistakes.
Maternity services at Shrewsbury and Telford hospital NHS trust were strongly criticised by an inquiry commissioned by NHS England into the death in 2009 of a baby, Kate Stanton-Davies.
In the email exchanges with the GP, Tapp, writes: “I have just finished a clinic at the Ludlow community hospital and have found another raft of tests that are simply cc’d to GPs without information going to GPs. I was informed by the senior sec[retary] that the process of cc results to GPs as they arrive in the community hospitals has been in place for 30 years. Does this need to be unpicked as well!! I suspect so.”
Another email states: “([name redacted] can you check on this and ensure that we are informing patients of abnormal results). The place for you to contact for any discussion was not ticked ([name redacted] can you look into this matter).”
In response to an example given by the GP of a test result inadequately dealt with by the trust, Tapp said: “Hopeless. [name redacted] can you look into this matter. I am fairly stunned that any one would have just popped this result into the post without context. I am not sure where a result sent to Ms M Midwife would go but can you ensure an effective educational program for colleagues.”
He goes on to say: “There does seem to be a bit of disconnect of brain here … The previous context does not seem to have been taken into consideration.”
He also adds: “I think there are some real problems here but there are opportunities to improve.”
Dr Edwin Borman, medical director at the Shrewsbury and Telford hospital NHS trust, said: “Effective and high quality communication between medical colleagues in primary and secondary care is extremely important for safe patient care.”
He said the trust – which handles 4,700 deliveries a year – had created a working group of consultants and GPs to review standards of communication following a patient’s discharge and would “continue to monitor and evaluate process to ensure continual improvement”.
Medics employed by the trust are the focus of both internal and external inquiries and at least four midwives are being investigated by the Nursing & Midwifery Council, according to a report in the Mirror.
The trust’s chief executive has apologised to the families of babies who died and said the trust was cooperating fully with the NHS review. But he added that it was his “firm belief” that the trust provided safe care for mothers and babies.
The health secretary, Jeremy Hunt, ordered an investigation into the deaths of a number of babies at the trust after seven deaths were judged to have been avoidable and bereaved families and the local coroner criticised the quality and safety of maternity care.
Five of the deaths involved apparent failures by staff to correctly monitor a baby’s heartbeat. Borman said the rate of baby deaths was no worse than anywhere else in the NHS.
"Hopeless": how senior doctor described NHS maternity unit"s testing regime
