Scandal-hit NHS trust in center of infant mortality assessment receives its FOURTH warning in eight months from CQC about the safety of its emergency services
- Shrewsbury and Telford Hospital Trust warned of the lack of pediatric staff
- Young emergency patients received no care in the 15-minute national guideline
- The latest in a series of scandals in which besieged trust is investigated for infant mortality
An NHS trust at the center of a pregnancy scandal has received its fourth warning in eight months about the safety of its services has been revealed.
Shrewsbury and Telford Hospital Trust were told it was after one inspection in the maternity departments and emergency departments in April.
The Care Quality Commission (CQC) struck confidence with a warning from paragraph 31 – meaning it can be closed if no changes are made.
It is the newest development after a series of scandals of the besieged trust that the Princess Royal Hospital of Telford and the Royal Shrewsbury Hospital manages.
Shrewsbury and Telford Hospital Trust have received the fourth formal warning for the safety of their services in eight months. Trust manages Telford’s Princess Royal Hospital and the Royal Shrewsbury Hospital (photo)
Two of the previous warnings were also formal notifications of paragraph 31.
The most recent warning arose from concerns about a lack of staff in the emergency departments of trust – in particular a lack of pediatric staff.
Edwin Borman, medical director for SATH, said: “We could not see all of our patients within 15 minutes, in accordance with national performance targets, and some of our patients left before we could begin treatment.
“We have alerted our family colleagues to children who left our EDs before treatment, which was the main focus of the CQC.”
WHEN WERE THE FOUR WARNINGS GIVEN?
Shrewsbury and Telford Hospital Trust have received four warnings about the safety of its services in eight months.
They were quickly issued in succession by several watch dogs.
Similar issues were raised in the cases.
The most recent came this month, after an inspection of the maternity departments and emergency services.
The Care Quality Commission (CQC) has issued a paragraph 31 which warns of concerns about a lack of staff in the emergency departments of the trust – in particular a lack of pediatric workers.
CQC could not go into details because it said it should give confidence the opportunity to appeal.
But the SATH medical director admitted that the staff was unable to see all emergency patients within the 15-minute national guideline.
CQC issued three urgent warnings following an inspection at the emergency services and maternity departments of the trust in August.
Two section 31 warnings were issued on maternity care and emergency care.
And a less serious section 29A warning was issued for its medical care, critical care and emergency and emergency services.
The confidence was told that it had until March to tackle the many mistakes.
The third warning from SATH came in October when it was told it had until March to address a lack of pediatric staff in the emergency department, risk assessments for malnutrition and pressure ulcers not being performed – as well as a lack of adviser and nursing staff within the intensive therapy unit.
The development comes as an independent assessment was launched in more than 250 cases of poor maternity care at SATH in the past two decades.
Former health secretary Jeremy Hunt launched the investigation into 23 infant mortality in the hospital in April 2017.
But after the review was announced, dozens of families came forward.
In September 2018, the West Midlands Quality Review Service warned SATH of the lack of trained staff for resuscitation in children.
The report noted that pediatric staff was only available Monday through Friday from 9:00 AM to 10:00 PM and on Saturday and Sunday from 12:00 PM to 10:00 PM.
It added: “A registered health care professional with level one Royal College of Pediatrics and Child Health competencies was not always available at the Royal Shrewsbury Hospital after 10 p.m. when no pediatric staff was present.
“Reviewers were of the opinion that a child could arrive after 10 p.m. and needed CPR and that a staff member with the right skills to lead CPR might not be available.”
Nigel Lee, chief operating officer at SATH, said: “In April we saw a huge increase in emergency demand in Shropshire with more than 20 percent more visitors and 30 percent more ambulances in our emergency departments.
“Our employees work incredibly hard to meet this demand, while we wait for our new recruits to start with us in June.
“The trust has spent more than £ 1 million this year on additional staff for our EDs and when these new nurses and doctors start, we can be confident that the service will continue to improve and meet all our commitments.”
Amanda Stanford, deputy chief inspector of hospitals at CQC, said: “CQC inspected maternity care and ED services at Shrewsbury and Telford Hospitals Trust in April.
‘That is why we have taken further urgent action with regard to ED care, including pediatrics. We cannot provide further details at this time, but will report on our findings soon. All CQC promotions are open to appeal. We follow the trust closely and maintain contacts with NHSI and NHSE. ”
What was Shrewsbury and Telford Hospital Trust’s baby scandal?
In April 2017, the then Minister of Health Jeremy Hunt launched an independent assessment in the hospital after it appeared that seven babies had died unnecessarily.
But after the assessment was announced, dozens of families came forward to investigate 23 baby deaths and 250 cases of poor maternity care at SATH in the past two decades.
It turned out that not following the heartbeat properly played a role in five deaths, while two others appeared suspicious.
Most deaths occurred between 2014 and 2016, while one of the preventable deaths already occurred in 2013.
Investigations or legal action against the Trust showed that seven of the dead were avoidable.
A study by the Trust found that two babies died due to lack of oxygen in the brain “contributed by a delay in recognizing deterioration of the fetal heart traces and the missed chances for earlier birth”.
A monitor used in hospitals, called a cardiotocograph, can give an indication of how the fetal heartbeat responds to the stress caused by the mother’s contractions. It has been used for decades, but mistakes are still being made.
The NHS Trust of Shrewsbury and Telford Hospital delivers approximately 4,700 babies every year.