NHSI accused of 'cover up' over maternity deaths investigation

In an unprecedented move, NHSI has set up a so-called “independent review panel” to review the interim findings of the independent investigation of Shrewsbury and Telford Hospitals Trust, which was ordered by former health secretary Jeremy Hunt in 2017.

This panel includes NHS Improvement medical director Kathy McLean, NHSI’s chief nurse for the Midlands and East region Siobhan Heafield, and NHSI’s head of quality governance in the nursing directorate Lorna Squires.

The panel also includes Gill Walton, chief executive of the Royal College of Midwives, and Lesley Regan, president of the Royal College of Obstetricians and Gynaecologists. CQC deputy chief inspector Nigel Acheson is the final member of the panel.

Midwifery expert Donna Ockenden is carrying out the probe into more than 200 cases of alleged poor care, including the deaths of babies and mothers as well as stillbirths and newborns being left with significant brain damage. She has assembled a panel of clinicians including midwives, obstetricians, neonatologists, paediatricians and anaesthetists to carry out the work.

Her investigation was widened from an initial 23 cases after HSJ exposed more deaths at the trust in 2017. The CQC placed the trust into special measures last year and highlighted concerns about safety in the maternity department.

One source close to the issues last year said the scale of problems at the trust “could put Morecambe Bay into the shade”.

An interim findings report has been reviewed by the NHS Improvement panel ahead of being published in the coming weeks. It is not clear what role the NHSI panel has had and whether it requested changes to the report.

Rhiannon Davies, whose daughter Kate died as a result of avoidable errors at the trust in 2009, told HSJ: “Every member of this apparently independent panel has a conflict of interest. The RCOG was paid by SATH to do a review of its services; the RCM and its normal births agenda is implicated in this as SATH is an outlier for normal birth and NHS Improvement and the CQC should have acted on concerns years ago.

“Unquestionably they are trying to cover it up. That is shocking. This is a secretary of state ordered investigation and the NHS is trying to interfere in it. This could be a positive opportunity to have real deep learning for the whole NHS.”

Ms Davies, who had to fight for years to expose multiple failings in her daughter’s care, added she would consider legally challenging NHS Improvement’s decision to set up the panel.

“We have no idea what changes they might be making to the investigation report. There is no transparency and we can’t trust them,” she said.

Despite NHSI’s role in regulating Shrewsbury and Telford Hospitals Trust since 2013 NHS Improvement repeated its claim the panel was independent in a statement to HSJ.

Medical director Kathy McLean said the “independent panel of experienced clinicians and stakeholders will provide an additional level of scrutiny to this complex and wide-ranging review and will ensure there is consistency in the approach taken to reviewing each case.

“The review remains independent and NHS Improvement will ensure that families are given the answers they need and that lessons are learnt.”

 A spokeswoman for the RCOG said it ”refutes any suggestion that its position is compromised. As the president of the RCOG, Prof Lesley Regan has a responsibility to make [the college’s] expertise available whenever problems are identified. It is in this context that she agreed to contribute to the NHSI review panel.”

The RCM issued a statement saying it was committed to improving safety and there would be key lessons from the Ockenden review but it did not substantively address the concerns about the NHSI panel. 

• UPDATE: In a statement issued by the Department of Health and Social Care a spokeswoman said the NHS Improvement panel “will have absolutely no control over the content or conclusions of the report.” She added that the NHSI panel would provide “additional support” to ensure the Ockenden review was rigorous and families go the answers they deserve. ”We are taking the patient safety concerns at Shrewsbury and Telford extremely seriously - the independent Ockenden Review will ensure the trust is equipped to learn from every tragic case where care fell short of the high standards patients expect,” the spokeswoman added.