A National Patient Safety Investigation into the maternity services at Nottingham University Hospital NHS Trust (NUH) following the death of Baby Harriet Hawkins has identified 13 significant care and service delivery problems and has concluded that Harriet’s death was “almost certainly preventable.”
Harriet’s parents, Jack and Sarah Hawkins, have had to wait over one and a half years for the Root Cause Analysis Investigation Report (dated 11/12/2017) to be released.
Prepared following an official external investigation into the circumstances surrounding Harriet’s death – who died during labour – the report is a damning indictment not only of the Trust’s failings in the maternity care given to Sarah, but also the failings in care after Harriet’s death and by the lack of openness and candour with Sarah and Jack who were simply trying to find out why their much-loved baby daughter had died.
The couple have had to fight every step of the way for this investigation to be carried out, having identified at the outset that the hospital’s explanation for Harriet’s death as “an infection” was untrue and hid the appalling catalogue of failures by the medical and midwifery staff caring for Sarah, “lack of midwifery leadership” and “poor safety culture” within the Trust.
The family’s lawyer, Switalskis Director and head of Clinical Negligence (Sheffield), Janet Baker, said: “This report is so damning that we are considering the unusual step of referring a number of the staff involved in Sarah’s care to their professional disciplinary and regulatory bodies and asking the Health and Safety Executive and Crown Prosecution Service to respectively investigate the systemic and institutional failings and the lack of candour identified in the report.”
The UK has one of the highest stillbirth rates in Europe and on 28th November 2017, Health Secretary Jeremy Hunt announced in Parliament details of the government’s strategy to reduce the number of stillbirths, neonatal deaths, maternal deaths and brain injuries that occur during or soon after birth by 50% by 2025. By failing to be open about incidents and be willing to not only learn from mistakes, but properly investigate incidents to identify the root causes, trusts can never hope to achieve this target.
With his pledge made on 28th November, Jeremy Hunt also made the very welcome announcement that families who suffer the trauma of stillbirth or whose babies have lifelong conditions such as cerebral palsy will automatically have an independent investigation to find out what went wrong and why. He also announced that he would be looking closely into enabling coroners to hold inquests into the stillbirths of babies born after 24 weeks gestation. This is something that Jack and Sarah have been campaigning for since Harriet’s death.
As a Clinical Director in NHS Improvements, Jack Hawkins is familiar with NHS national policies and guidelines. Mr Hawkins said: “What this report doesn’t address and which was outside the remit of the report is all the other policies that the Trust has breached, such as the NUH whistleblowing and staff sickness policy. There is no doubt that we have blown the whistle on bad practice and management at the Trust where we are both employed. However come January 2018, I will have no job with them and Sarah will be on half pay and likely no pay in 4 months’ time’. We are both unable to work because of the psychological and psychiatric impact Harriet’s death has had on us. The conduct of the Trust towards us is compounding that impact.”
“The sad thing is, had we taken up the unwritten offer of automatic Consultant-led care provided to senior NUH staff, Harriet would be with us today” said Sarah Hawkins. “But the truth, is we trusted all staff at the NHS, irrespective of their level of seniority, and didn’t want to take up valuable consultant resources when I had an entirely normal and low-risk pregnancy.”