Health committee's frustration at hearing about county's 'significantly worse' child mortality rates through media

Members of the county's Joint Health Overview Scrutiny Committee raised the issue with representatives of Shrewsbury & Telford Hospital NHS Trust (SaTH) at a meeting this week.

Responding, Dr John Jones, medical director at the trust, which manages both Royal Shrewsbury Hospital (RSH) and Princess Royal Hospital (PRH) in Telford, said external consultants are currently carrying out a review to see if there is "anything we are missing".

It comes after figures from NHS Shropshire, Telford and Wrekin's Integrated Care Board (ICB) revealed that child mortality rates in the county were "significantly worse" than the national average – and were the highest in the country as a standalone year.

Addressing members of SaTH's board, David Sandbach, a lay member of the committee and former chief executive of PRH, said the matter had not been raised on two occasions the trust had visited the committee to discuss progress on the Ockenden Review – which revealed harrowing failings in maternity care delivered by SaTH over a number of years.

He said: "What I am annoyed about is that during those two presentations the committee was not given sight of your neonatal data.

"And why were we not given that? Because we would have been able to ask questions.

"But what we got was 'everything is sunny in the garden', 'we have turned the corner', 'we have got a lot more staff', and you in fact sent us your detail of your staffing structure and it has gone up, you invested at least a million, maybe two million more in that service – but we were not told about this critical piece of data."

Responding, Hayley Flavell, director of nursing at SaTH, said the previous meetings had been focussed on the response to the Ockenden Review, and that time had been limited to 30 minutes.

She said: "I came initially to speak to you all about maternity and we were asked to talk about the Ockenden updates. That's what we were asked to talk about, we were asked to talk about what has changed following the publication of the first report and the second report, and that's what we did.

"We only had I think half an hour so we talked very much about our methodology, the improvements we made, and some of the outcomes in terms of staffing, governance, and leadership."

Councillor Kate Halliday, a member of the committee, said members would rather have learned the information from the trust – and not the media.

She said: "I think David raised the issue of why didn't we hear about the maternity data on the presentation we had on the Ockenden report.

"I accept the explanation there but also it kind of goes back to, an action plan can be looking really good and the processes can be worked through but there probably has to be something around the outcomes.

"Ultimately this committee wants to support you in providing the best care, and we are intimately involved in that process, and I think this committee would probably rather have heard about this issue, not from the Shropshire Star, which is where I picked it up, but perhaps from you as providers, so we could work together to actually try to address these issues.

"Because by not hearing about them there has been a history in this area of trying to cover things up etcetera, and I am not suggesting that is what you have done, but we need to work together to better understand the problems perhaps as they are occurring so we can work together to put them right.

"And I do think some of the data and not just the action plans are quite important to this committee."

Committee member, Councillor Derek White, reminded members that they had never been told of issues before the Ockenden review took place.

He said: "I was fortunate enough to be the chair from the time we had single hospitals and effectively we went all through the Ockenden years and quite frankly never once did we hear there was a problem. Never once.

"And that caused us a huge amount of embarrassment. Not embarrassment, but shame, as though we had failed here in our duty."

Addressing the issue over the mortality rates specifically Dr Jones said they mirrored the West Midlands and region-wide work was taking place to understand why.

He said the external consultants are assessing if anything has been missed by the trust, but added that one issue could be high rates of mothers smoking at the time of deliver.

He said: "You are right to draw attention to, both in the West Midlands at large and in babies born at SaTH there is an above average neonatal mortality and it is likely there is an overlap between factors that influence neonatal mortality locally as there are in the West Midlands.

"It is something we have been trying to understand in a lot more detail.

"We have actually got an ongoing at the moment, external expert review looking at our neonatal mortality over a two year period just to say 'look is there anything we are missing'.

"We can't wait until the wider West Midlands conclusions, we want to know what are the conclusions for our local population.

"So we are in the middle of that and it will finish in the next two or three months, just to see if there is anything we are not seeing.

"But it is clearly very important. I have said publicly on a number of occasions any child death, we need to understand why any child dies.

"I deliberately do not talk about numbers because as I said earlier a child death, a neonatal death is a total tragedy, no matter how predictable, and I know families never recover from it, no matter the circumstances. So we have to try and address every death that occurs on its own and understand why it happens, and support families both at the time and afterwards, and I think the Ockenden Review has drawn attention to the fact we have not done that well at all in the past.

"So all I can say is we are really looking at it in detail to see if there is anything we are missing.

"We have got external experts looking at that and we will listen to what they say.

"If there was something that I knew that we were not doing that was influencing that, and must have been influencing it over a number of years, then we would act on it.

"The one thing I think is worth highlighting because it is a broader instance is the issue of smoking at the time of delivering.

"We know we have got quite a high percentage of mums who are smoking at the time of delivery.

"Giving up smoking is incredibly difficult and I think we should all do all that we can to support mums and their wider families to try and give up smoking preferably before they even think about getting pregnant."