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Action against Medical Accidents (AvMA) is a charity for patient safety and justice.  They provide support and  free independent advice to people who have been affected by medical accidents.

We have just renewed our firm’s AvMA’s Lawyers Service subscription. BTTJ Solicitors Tom Barnes and Richard Stanford are both AvMA panel members.  If you feel you have suffered from medical negligence, please get in touch.

Adam Lloyd joined us as a Solicitor in our Medical Negligence Department in March 2022.

Adam joined us from a local Solicitors firm and previously worked as a Personal Injury and Clinical Negligence Solicitor.

Outside of work Adam enjoys watching rugby especially Northampton Saints, visiting historic buildings and listening to classical music.

The long-awaited final report of Ms Donna Ockenden, Senior Midwife was published earlier this week, on 30 March 2022.  This report follows on from Ms Ockenden’s previous report published in December 2020.

 

Ms Ockenden was assisted in preparing the report by an independent team of medical professionals in various areas including obstetrics, neonatology, obstetric anaesthesia, physician, cardiology and neurology.

 

The review forming the basis of the report is the largest ever inquiry in the history of the NHS into a single service.

 

Whilst Ms Ockenden clearly acknowledges the difficult and much appreciated work carried out by NHS staff throughout the country, which continues in often challenging circumstances, especially considering the Covid pandemic, she has highlighted some truly shocking failures in the quality of care provided and governance at the Trust.

 

The report also highlights failures from bodies external to the Trust to effectively monitor the care provided by the Trust.

 

Background

 

The Independent review was commissioned by the then Secretary for State for Health and Social Care, the Right Honourable Jeremy Hunt MP in 2017.   The review was prompted by the parents of Kate Stanton Davies and Pippa Griffiths whose daughters had died at the midwifery-led units run by The Shrewsbury and Telford Hospital NHS Trust, as a result of the care they received in 2009 and 2016 respectively.

 

As noted by Ms Ockenden:

 

“This review owes its origins to Kate Stanton Davies, and her parents Rhiannon Davies and Richard Stanton; and to Pippa Griffiths, and her parents Kayleigh and Colin Griffiths. Kate’s and Pippa’s parents have shown an unrelenting commitment to ensuring their daughters’ short lives make a difference to the safety of maternity care.”

 

The review was originally concerned with 23 families’ cases, as identified by the parents of Kate Stanton Davies and Pippa Griffiths to Mr Hunt.  The number of cases and the scope of the review increased substantially and Ms Ockenden’s review took evidence from 1,486 families, regarding 1,592 clinical incidents mostly occurring between 2000 and 2019.  Although the earliest incident occurred in 1973 and the latest in 2020.

 

Report Findings

 

As noted above, the report found repeated failures in the quality of care and governance over the period considered, together with failures of external bodies to effectively monitor the care provided.

 

The review found repeated errors in care, which led to injury to either mothers or, their babies.  All aspects of clinical care were considered in maternity services.

 

The review identified continued failures to follow national clinical guidelines in many areas for example, the monitoring of fetal heart rate, maternal blood pressure, management of gestational diabetes or resuscitation.

 

The report presents specific incidences including those of Kate Stanton Davies and Pippa Griffiths and the strikingly similar circumstances of prior cases.

 

There were delays within the Trust to escalate matters to more senior specialists and a failure to work collaboratively across disciplines.  The results of these systemic failures were truly tragic and led to serious medical conditions such as sepsis, hypoxic ischaemic encephalopathy and death.

 

The report highlighted a fear of midwives to express their concerns to consultants within the Trust, resulting from poor working relationships.  This culture of fear was combined with staffing problems and a lack of training.  These difficulties were played out in front of families, which put additional stress on parents at times when they were at their most vulnerable.

 

The review detailed repeated circumstances where families were not treated with the sympathy or, compassion they should have expected.  With clinicians unprepared for follow up discussions, not dealing appropriately with complaints, giving inaccurate information and even blaming the parents themselves for the outcomes.

 

Within the Trust there was an emphasis on promotion of natural birth, with a reluctance to perform caesarean sections.  This directly resulted in babies dying during or, shortly after birth or, alternatively being left with catastrophic, life-long heath conditions.

 

The review’s consideration of clinical governance processes shows that investigatory processes were not followed to a standard that would have been expected. As noted by Ms Ockenden:

 

“The reviews were often cursory, not multidisciplinary and did not identify the underlying systemic failings and some significant cases of concern were not investigated at all. In fact, the maternity governance team inappropriately downgraded serious incidents to a local investigation methodology in order to avoid external scrutiny, so that the true scale of serious incidents at the Trust went unknown until this review was undertaken.”

 

This meant that there were missed opportunities to learn from the incidents occurring within the Trust with continued and repeated serious mistakes and omissions, leading to further avoidable injuries and deaths to Mothers and babies.

 

Figures

 

The report graded the care provided in four categories as follows:

 

0, Appropriate, Appropriate care in line with best practice at the time

1, Minor concerns, Care could have been improved, but different management would have made no difference to the outcome

2, Significant concerns, Suboptimal care in which different management might have made a difference to the outcome

3, Major concerns, Suboptimal care in which different management would reasonably be expected to have made a difference to the outcome

 

The review listed five major incident categories; Maternal death, Stillbirth, Hypoxic Ischaemic Encephalopathy, Neonatal death and Cerebral Palsy/Brain damage.

 

The review found that for the care provided in categories 2 and 3, and consequently avoidable outcomes, there were Nine maternal deaths, 131 still births, 70 neonatal deaths and 94 cases of brain damage.

 

Future Developments

 

The report identified more than 60 specific Local Actions for Learning for Shrewsbury and Telford Hospital NHS covering nine areas and another 15 Immediate and Essential Actions for all maternity services in England.  The aim of these actions is to improve all maternity services in England, including financing a safe and sustainable maternity and neonatal workforce and ensuring appropriate training for all those involved in maternity services.

 

The report acknowledged the recent announcement of £127 million by NHS England for maternity services but noted that this was significantly short of the £200-£300 million recommended in June 2021 by the Health and Social Care Select Committee.

 

Comment

 

The individual mistakes identified within the investigation are, sadly, nothing out of the ordinary and are regularly encountered in our work.  What is striking, however, is the shear scale of the problem and the number of families affected, suggesting a significant cultural problem within the trust.

 

If you have been affected by failings in maternity care, then please feel free to contact us for free and informal initial guidance on the options available to you.

Jonathan Rose qualified as a Solicitor in 2012.

Jonathan joined BTTJ as a Solicitor in January 2022. Jonathan joins us from a local firm, previous to this Jonathan worked at a firm in Northampton.

Jonathan has experience in dealing with a wide range of Medical Negligence matters including Orthopaedic, Urological and Ophthalmic, injuries occurring as a result of surgical error, delay in the diagnosis of cancer and cauda equina syndrome.

Outside of work Jonathan likes to spend time with his young family and newly acquired puppy.  Jonathan is a keen supporter of football and rugby and coaches his son’s rugby team – Old Laurentians in Rugby.

“My route into Law was an unconventional one: after a career as a Nurse and an NHS manager, I made the transition to Medical Negligence law.

I began my career studying for a BSc (Hons) in Applied Science. I then trained in general and mental health nursing, qualifying as a registered mental health nurse (RMN). As a nurse with a degree, I soon became a manager, running a drop-in centre for a mental health charity and community mental health services for a council.

In the years that followed my career was focussed on the improvement of public sector services, working in roles at:

  • District Audit/Audit Commission
  • NHS Modernisation Agency
  • National Institute of Mental Health in England (NIMHE).

I consolidated my management learning by completing a master’s degree in public administration (MPA) at Warwick University, where I had the opportunity to study in South Africa and the USA.

The MPA course was meant to set me on a journey to becoming a public sector director and/or chief executive, however whilst working for a director in a large hospital trust, I became increasingly concerned about the medical errors I was investigating, and the reluctance of the hospital trust to admit their liability. This concern led me to study law.

When I commenced a Graduate Diploma in Law (GDL), it became apparent how challenging it would be combining legal studies, with a full-time job in the NHS and family commitments. I therefore changed roles and worked as a locum inspector for the Care Quality Commission (CQC), where I planned inspections around my first year of legal studies. I subsequently moved to review criminal cases for the Criminal Cases Review Commission (CCRC), where I completed my second year GDL, leaving CCRC to study the Legal Practice Course (LPC) full-time.

Finding a solicitor training contact, given my unorthodox background, was a challenge, however I was soon recruited by specialist personal injury firm in Manchester, qualifying as a solicitor in July 2021.

Why did I join Brindley Twist Tafft and James in Coventry?

I knew when I qualified as a solicitor that I wanted to work in medical negligence law. It was clear to me that my nursing and NHS experience, when combined with my audit/inspection experience provided me with unique knowledge about the NHS, how it operates, and the reasons why medical negligence can occur.

I am fortunate to how found a firm that recognised my skills and experience acquired in my previous roles – Brindley Twist Tafft & James (BTTJ) in Coventry. I am now delighted to be working at one of the country’s leading Clinical Negligence departments and bringing my unique background to the claims process for the benefit of our clients

As a newly qualified solicitor I am surrounded by a team with many years’ experience working in the field of clinical negligence. I am impressed with the level of care and attention that each member of the team gives to clients and potential clients from the moment they make contact with us.

I look forward to becoming an integral member of the team, and to successfully working with clients in pursuit of their claims.”

Julia French

Solicitor – Clinical Negligence

 

If you need any advice on a medical negligence case, then please get in touch with our expert team to see how we can help. We offer free, no initial consultations.

We’re pleased to introduce a new member of our firm here at BTTJ Medical Negligance

Julia joined us in September as a Fee Earner in our Clinical Negligence Department. She joined us from a Manchester based solicitors firm, and before that Julia spent over 4 years at the Criminal Cases Review Commission in Birmingham, as a Case Review Manager.

Before pursuing a legal career Julia worked in management roles for the NHS and social care sector, qualifying as nurse specialising in mental health, and completing a masters degree at Warwick University.  Julia has also worked as an inspector for the Audit Commission and Care Quality Commission..

 

Clinical Negligence litigation relies on the opinion of medical experts, to identify and establish breach of duty, causation and quantum issues. Many of these medical experts work in both public and private sectors and many of whom have been called forward to healthcare’s front line in the fight against Covid-19. This has created a shortage of available experts to give evidence on liability and/or quantum to support both the Claimant and Defendant.

In 2020, a new protocol was implemented to encourage positive behaviours from Claimant and Defendant lawyers. This protocol can be relied upon throughout the duration of the Covid-19 pandemic and recovery.

This protocol covers issues relating to limitation and extensions of time, telephone calls and emails, service by email (including new proceedings), medical examinations of clients for condition and prognosis reports, exchange of evidence, interim payments, settlement meetings and mediations, BACS payments, cost budgeting, and hearings including adjournments.

[Further information on the protocol can be found at: https://resolution.nhs.uk/wp-content/uploads/2021/03/Covid-19-Clinical-Negligence-Protocol-2020-1.pdf ]

 

How Covid-19 has affected us:

The impact upon disclosure of Medical Records

The first stage of a Clinical Negligence claim is for us to access and review the medical records with our experts.  Some NHS trusts and GP practices have risen to the challenge and have continued to provide records within the statutory timescale of 30 days (GDPR 2018), whereas others have struggled significantly, with records taking many months or more to materialise.

 

It is a difficult call to make to seek a Court order for disclosure (which is the only way to force the issue), when we are all acutely aware of the challenges posed by the pandemic.

 

The impact on limitation

The Covid-19 protocol allows for an unchallengeable extension to limitation until 3 months after the end of the protocol (for participating organisations).  This has the potential to lead to a significant number of cases where limitation occurs on the same (as yet unknown) date 3 months after the end of the protocol.

 

In order to avoid this backlog, we seek to agree a fixed limitation date for each file and review and extend it further if necessary.

 

The impact of self-isolation and working remotely

Like many companies, the pandemic led to a shift in our working dynamics, with all staff initially forced to work remotely.

 

Since the easing of restrictions many of our staff have been making a phased return to the office. We are also pleased to return to client-facing meetings, where necessary, socially distanced in one of our meeting rooms.

 

More recently, the NHS Track and Trace app has caused its own challenges with ‘pings’ to numerous members of the team, forcing them to self-isolate for up to 10 days.   Thankfully working remotely is no longer an upheaval and our usual service remains.

Joining the firm in 2021 brought new challenges. Starting a new job in the in the midst of remote working was somewhat daunting as many of our colleagues have yet to return to work in the office. We found that we may know a name from through email, or over the phone, but it proves difficult putting a face to that name when people do attend the office.

 

The impact of Covid-19 on our work in the future

Covid-19 has caused significant delays within the healthcare sector, with many individual’s treatments being pushed back. Recent news suggests that a potential 13 million patients may be waiting for routine procedures and investigations to be carried out in the next 12 months [https://www.bbc.co.uk/news/uk-57793122].

 

These delays will undoubtedly lead to an increase in avoidable poor outcomes for patients and their families.

 

For legal advice relation to Clinical Negligence contact us at medical@bttj.com

 

We’re pleased to introduce two new members of our firm here at BTTJ Medical Negligance

Elizabeth Bellamy & Kirsten Walker joined us as Paralegals at the beginning of June 2021

Elizabeth completed her Law degree at The University Of Law & Kirsten completed her Law degree at Manchester Metropolitan University.

We’re delighted to announce the appointment of a new partner of BTTJ Medical Negligence, Richard Stanford.

Richard joined the Medical Negligence Department in 2010 following a career at the Law Society and Solicitors Regulation Authority. He became a partner at BTTJ in 2021, remaining in his respective department.

 

Image of Richard Stanford - Medical Negligence Solicitor