Managers at an NHS hospital misled the parents of a stillborn baby about failures in its maternity care, apparently putting the protection of its reputation above learning lessons from the mistakes, the health ombudsman has found.
Dame Julie Mellor said the trust running Leighton hospital in Crewe had made "highly misleading" statements to the dead boy's parents, while its then head of midwifery had been "dishonest".
The ombudsman's report – which covers the incident in May 2009, the subsequent investigations by the Mid-Cheshire Hospitals foundation trust running the hospital and an external review by another NHS trust – finds the trust guilty of maladministration. Mellor says the trust must acknowledge and apologise for its failings and pay the couple, identified only as Mr and Mrs D, £1,000 as compensation for the "injustice" they suffered.
The trust has already paid the couple £30,000 in an out-of-court settlement in October 2010. It said it had identified a number of shortcomings in Mrs D's care, but was unable to say whether, but for these, the baby would have survived. It made no defence with regard to breach of duty or causation.
The head of midwifery at the time, Sandra Smith, who still holds an important advisory role on antenatal care, was given a final warning by the trust for her behaviour.
The couple reported Smith and five other staff to the Nursing and Midwifery Council, their professional disciplinary body, which said, after two reviews by investigation panels, that they had no case to answer. The General Medical Council told the couple just before Christmas it had investigated the case and would not be taking further action.
The ombudsman's findings, sent to the couple in November, come as ministers prepare to impose a "duty of candour" on NHS organisations and amid concerns over stillbirths, nursing care and the state of maternity services. In summer 2012, the Mid-Cheshire trust won an award from healthcare analysts CHKS, part of the Capita group, as the most improved in England and one of the top 40 trusts in the country.
Mrs D, who was 36 when she became pregnant, should have been treated as a high-risk pregnancy because of her age, history of depression and epilepsy, and high body mass index. The hospital's own review of the incident found the failure by a midwife to perform a particular scan had lost the opportunity "to deliver the baby possibly alive", the ombudsman's report reveals.
The Guardian has seen the report, which says guidelines for women with risk factors were not in practice, guidelines for women with epilepsy were not in circulation, and electronic foetal monitoring was not performed as it should have been.
An external review commissioned by the trust, issued in September 2010, said Mrs D should have been seen by a consultant, as she was high risk, there was no formal management plan of care and it was unclear whether she was on a high-risk pathway. The review said the trust should also consider whether there was a tendency for the hospital's obstetrics unit to dissuade women from coming into hospital until the last moment, and that the case gave the impression that staff were either concerned about workload or unwelcoming to women.
In finding maladministration, the ombudsman said: "During their reviews, the trust identified several failings in Mrs D's antenatal care. However, I have found that [the trust] subsequently gave Mr and Mrs D information that contradicted their findings and were inaccurate." The couple only discovered these contradictions when they instigated legal action and asked for documents.
The ombudsman said the head of midwifery had claimed she had discussed events with two midwives involved in Mrs D's care, which she had not; and that she had given "a false impression" that one midwife had been removed from clinical practice for two weeks when this was not the case.
The ombudsman said that in the light of this, and taking account of the former chief executive's statement that the head of midwifery told "a number of lies" at a meeting, "it is clear that the head of midwifery made statements to Mr and Mrs D that she knew to be untrue".
The trust had made "several statements that were highly misleading and they omitted to share important conclusions from their serious incident review". Having established the facts, "the trust failed to provide Mr and Mrs D with accurate evidence-based explanations and did not acknowledge their mistakes or apologise for them", said the ombudsman. "Their actions fell so far short of the applicable standards that they amounted to maladministration."
The ombudsman also said she could understand why the trust's "lack of transparency and failure to take action to put things right left Mr and Mrs D with the sense that, rather than learning lessons to improve their antenatal care, the trust have prioritised protecting their reputation".
By early next year, the trust must demonstrate it has learned lessons from its failings, and produce a plan and timescale to put things right. Mellor hoped her report would draw "what has been a long, complex and distressing complaints process to a close".
Mrs D said that, when she learned the ombudsman's verdict, "I collapsed in a heap. I broke down in tears. This was the first time that the evidence provided to all regulators and organisations had been interpreted correctly. To think any couple could go through what we went through makes me shudder."
Mr D said: "We were used to being disbelieved. For three years our evidence was questioned, queried and dismissed. It was like fighting a faceless monolith. This is a seismic shift."
Eddie Jones of Manchester-based solicitors JMW, who represented the couple in the legal action against the trust and advised them in their complaint to the ombudsman, said the hospital had committed a "catalogue of clinical errors".
Although he thought the NHS was more willing than in the past to admit mistakes, he said: "There are pockets of practitioners and managers whose immediate response is to not give too much away – 'let's not admit to what has happened'. This is the most glaring example I have come across. It is a prime example of why a duty of candour is required."
Smith now works for the Ashton, Leigh and Wigan primary care trust and is the north-west England regional clinical lead on antenatal, newborn and child health screening for the UK National Screening Committee, which advises health ministers in the four countries of the UK. She declined to comment and referred the Guardian to the Mid-Cheshire trust, which said it would not comment on individuals.
Phil Morley, the Mid-Cheshire trust's former chief executive, now at Hull and East Yorkshire trust, also did not wish to comment.
The Mid-Cheshire trust, which said it had twice apologised to Mr and Mrs D for shortcomings, said changes had been implemented in its maternity services since the incident, most recently in refurbishment of the hospital's labour ward. It said the Care Quality Commission (CQC), the health service standards watchdog, had subsequently found maternity services to be "fully compliant" and the trust's complaints service robust.
The CQC said it had met Mr and Mrs D in 2010 and their concerns had triggered a review of the hospital in December that year, which looked at two areas: care and welfare of people, and medicines management. "Moderate concerns" were identified in both areas. Inspectors also examined the hospital's complaints handling procedures and found evidence to suggest that the trust had learnt lessons as a result of investigating the incident and was working through an action plan to resolve the issues.
"CQC carried out a scheduled inspection in July 2011. As part of this inspection we followed up to see that these action plans were in place and the hospital was found to be fully compliant," the commission said. "CQC has carried out a further scheduled inspection at the hospital on 5 December 2012 and the report from this will be published in January 2013."
The commission said it would determine the need for any further regulatory action in light of the ombudsman's findings.
The strategic health authority for north-west England, which has a statutory duty to monitor midwives, said it was reviewing the history of the case.
The regulator Monitor, which oversees foundation trusts, said it would consider whether the ombudsman's findings represented a breach of the trust's terms of authorisation. "We will then work with the trust to seek confirmation that any relevant action plan the ombudsman requires is fully discharged and that the underlying issues have been addressed."
THE 'DUTY OF CANDOUR'
A "duty of candour" will be included in all NHS commissioning contracts from April this year. Ministers say health organisations will be required to tell patients if safety has been compromised, apologise for mistakes and ensure lessons are learned.
Campaign organisation Action against Medical Accidents (AVMA) believes this will not go far enough and says statutory rules should be introduced. The Department of Health may have to consider again whether these are needed with the publication in January or February of the final report of a public inquiry into what went wrong at Mid-Staffordshire NHS trust, where between 400 and 1,200 patients are thought to have died as a result of poor care over four years.
The scandal happened despite the existence of a national standards watchdog, the Healthcare Commission, since replaced by what is meant to be a tougher body, the Care Quality Commission.
AvMA's chief executive, Peter Walsh, has described the introduction of a duty of candour as "an apparently cynical attempt" to sidestep support for a statutory duty and pre-empt the public inquiry report. He points out that such contractual obligations will not apply to GPs or dentists.
