Essential insight into NHS matters in the North West of England, with a particular focus on the devolution project in Greater Manchester. By Lawrence Dunhill
“When the baby was born alive and went on to live for almost two hours, the staff members involved in the care did not find a quiet place to sit with her to nurse her as she died, but instead placed her in a Moses basket and left her in the sluice room to die alone.”
Even for a relatively thick skinned journalist – well conditioned to reading grisly reports – there were parts of the recent report into care failings at Pennine Acute Hospitals Trust that were utterly heartbreaking.
This 22-week-old baby, born just before the legal age of viability, had no prospect of resuscitation, but should absolutely have received compassionate care during her short life.
The internal report on the trust’s maternity services was written in June, after being ordered by the trust’s new leadership team, but it was only released last week after a persistent freedom of information struggle by the Manchester Evening News.
It’s clear the problems at the trust are deep rooted and go back several years, but it’s particularly worrying that the June report cited problems with an “enduring culture”.
Depressingly familiar failings include low staffing levels, poor culture and patient outcomes, bad attitudes from staff, poor reporting of harmful incidents, and a reluctance to learn from mistakes.
In another appalling incident, staff failed to properly respond to a seriously deteriorating patient over a period of days, instead focusing on her “bizarre behaviour” and attributing her problems to mental health issues. The patient eventually died from a haemorrhage.
The trust first began investigating maternity deaths and problems with the service in 2014, with reviews and improvement plans continuing throughout 2015.
But the June report said: “Despite an external review taking place and significant actions being undertaken these have not affected positively on the culture within the service or made improvements in clinical outcomes, or the care for mothers and babies.”
This is extremely worrying stuff, and raises difficult questions at various leadership levels.
It appears major efforts were made to address the problems by former chief executive Gillian Fairfield, who commissioned the initial investigation when she joined the trust in April 2014, as well as by former chief nurse Gill Harris. Despite the trust’s overall inadequate rating, both were given some praise in the trust’s latest Care Quality Commission inspection report.
But this latest review suggests the efforts at halting the serious problems in maternity services ultimately came up short.
The report only surfaced thanks to persistent work from the MEN, which managed to force the trust to publish it after a long and frustrating FOI process, for which the provider has apologised.
The trust insists cock-up rather than conspiracy, and told HSJ: “There was absolutely no intention to delay the FOI process or to conceal anything.
“We have apologised to the MEN for the frustration and for the view that has been created that we have been less than helpful and open.
“We are looking into how this was handled and have identified some areas where we can improve.”
Pennine Acute Hospitals is now under the leadership of Salford Royal duo Sir David Dalton and Jim Potter, who clearly have quite a job on their hands to turn the ship around.
I’m not aware that the trust has received any national funding support, either for the temporary leadership arrangements or the developing “acute chain” between the trusts.
North by North West takes an in-depth fortnightly look at one of the NHS’s most challenged and innovative regions. There will be a particular focus on the devolution experiment in Greater Manchester, but my scope will also include Merseyside, Lancashire, Cheshire and Cumbria.
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- Acute care
- Care Quality Commission (CQC)
- David Dalton
- FRIMLEY HEALTH NHS FOUNDATION TRUST
- HEATHERWOOD AND WEXHAM PARK HOSPITALS NHS FOUNDATION TRUST
- Manchester devolution plan
- NHS Bury CCG
- NHS Heywood, Middleton and Rochdale CCG
- NHS North Manchester CCG
- NHS Oldham CCG
- North West
- PENNINE ACUTE HOSPITALS NHS TRUST
- SALFORD ROYAL NHS FOUNDATION TRUST