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Scandal of hidden patient safety reviews

Patient safety reviews have been effectively hidden from regulators and the public.

An investigation by the BBC has found that a review of maternity services at Doncaster and Bassetlaw hospitals carried out by the Royal College of Obstetricians and Gynaecologists in 2016, had identified serious patient safety concerns, but was never published

The review had been requested by the trust after a number of serious clinical incidents had been identified, including the lack of consultants.

The report has now been shared with a local couple, Beth and Dan Wankiewic, who have sought legal advice following the death of their baby boy. Clay died from multiple skull fractures shortly after his birth at Doncaster Royal Infirmary last July.

A junior doctor had twice tried to deliver the baby with forceps after having to get phone advice because there was no consultant on site. Eventually, the baby had to be pushed back up the birth canal so that a Caesarean section could be performed.

It was a further 30 minutes before the baby was born and despite attempts to resuscitate him, the couple were told that he had died.

A midwife later told the couple that she was being pressurised to say that the baby was stillborn, but she was sure he had been born alive. If a baby is stillborn there is no requirement for an inquest.

Beth commented: “My heart just dropped – reading point after point of things that resonate with us in Clay’s care that had been picked up in 2016. It was just heart breaking to know that they knew back then.”

The couple’s solicitor, Natalie Cosgrove, from our sister company, Switalskis, said that she had represented several families since the review where the issues identified have been a factor.

Maternity services at both hospitals run by the trust are currently rated by the hospital regulator as “Requires Improvement”.

It now seems that the report was just one of scores highlighting serious patient safety concerns in hospitals throughout the UK that have gone unpublished.

Freedom of Information requests by the BBC found that 111 reports have been written by medical royal colleges, which the NHS trusts have a duty to share. Despite this, of the 80 reports disclosed to the BBC, only 26 had actually been shared in full with regulators and only 16 had been published.

Dr Bill Kirkup, who led the 2015 investigation into the scandal at Morecambe Bay following the death of 11 babies and a mother, said that the findings were a “great disappointment.

“I can’t understand what the rationale would be for withholding the existence of a report or the findings of a report. These are important matters of accountability in the public service.”

You can see Natalie’s interview with BBC Look North here.

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