Report Highlights Ongoing Care Issues at Trust Following Infant Deaths

A review into the elevated number of infant fatalities at an NHS trust in Shropshire during 2022 has identified deficiencies in care and problems within its neonatal service. The assessment by the Royal College of Physicians indicates that additional scrutiny is warranted regarding the high death rates across the broader West Midlands area, in addition to those at Shrewsbury and Telford Hospital (SaTH) NHS trust. Concerning seven infant deaths, the report, which focuses on the “obstetric journey,” characterized the handling of issues as inadequate. SaTH has issued an apology for instances of substandard care highlighted within the document. SaTH documented a total of 18 deaths in the 2021-22 period, a figure 5% greater than that observed in trusts of comparable size. Neonatal mortality had also been elevated for the preceding three years. Consequently, the trust requested the Royal College of Physicians (RCP) to review its neonatal service. The 2021-22 timeframe coincided with senior midwife Donna Ockenden’s reporting on SaTH’s shortcomings, which resulted in 200 fatalities – then considered the most significant maternity scandal in the history of the NHS. In the current year, the Care Quality Commission has assessed the trust’s maternity services as good. The RCP stated that the general perception was of a maternity service that had made substantial progress over the preceding two years. Nevertheless, the report pinpointed only five instances of good practice in 2022. Two cases were deemed unsatisfactory, and ten presented opportunities for enhancement. A solicitor representing several families informed the BBC that she believed the RCP investigation did not entirely address some of her clients’ worries. The report concluded that the neonatal service in 2022 was more vulnerable than the maternity service and suffered from issues with nursing leadership. It noted moments of panic during infant resuscitations, specifically when attempting to intubate a baby. Furthermore, delays were observed during the “golden hour” following birth, a critical period when interventions like antibiotic administration could be crucial. Staffing deficiencies were also identified in neonatal care, with the trust having a limited number of qualified nurses and depending on agency personnel. Dr. John Jones, medical director for Shrewsbury and Telford Hospital, stated that the trust had contacted each of the 18 families whose infant’s care was examined and had commenced meetings with them to address inquiries and provide assistance. He remarked that while the review team “described examples of good care, there were also examples of poor care that should have been significantly better.” He concluded by saying, “We apologise wholeheartedly for this.”