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Exclusive: Homerton safety review after claims from 'unhappy midwives'

Commissioners have ordered an external review of the maternity unit at Homerton University Hospital Trust in the light of ongoing “safety concerns” raised by an anonymous group of midwives.

The review was commissioned by City and Hackney Clinical Commissioning Group to address claims made by the group, who call themselves the “unhappy midwives”.

The group has highlighted a number of serious clinical incidents and what they describe as “the avoidable deaths of mothers and babies in our maternity unit”.

In their most recent statement, circulated to the Care Quality Commission and senior figures including health secretary Jeremy Hunt, the group criticise the way their concerns have been investigated and claim “mothers and babies continue to be placed at risk”.

“The alleged concerns have been a cause of distress amongst those staff implicated”

Board papers

However, Homerton University Hospital Trust maintains the incidents have been investigated thoroughly and the unit is safe.

In a report to the trust’s board, chief executive Tracey Fletcher described the anonymous group’s campaign, which has included an online petition calling for the resignation of senior maternity staff, as “vindictive”.

Tracey Fletcher

Tracey Fletcher

Minutes from the trust’s September board meeting show the concerns were investigated by former chief executive Nancy Hallett while a further review by chief nurse Sheila Adam concluded all the cases in question had been “appropriately managed”.

“The alleged concerns have been a cause of distress amongst those staff implicated,” says the document.

“The trust has attempted to engage with the group and responded to their emails but to no avail and they remain anonymous.”

The board report states that a series of reviews of the maternity service – carried out by the CQC, the NHS Litigation Authority and a supervisor of midwives – had “not raised any significant concerns”.

Hackney and City CCG confirmed it had ordered its own review, which started in October last year, and was now awaiting the findings.

“The CCG was contacted by an anonymous person or persons suggesting they are midwives at the Homerton University Hospital Trust claiming concerns about safety issues at the trust,” said a spokesperson for the commissioning group.

“These allegations have been thoroughly investigated in the past by the trust”

CCG spokesperson

“These allegations have been thoroughly investigated in the past by the trust, as well as being part of CQC inspections where no maternity concerns were found.

“However, to assure ourselves City and Hackney CCG commissioned an external review, both of the issues raised and how they had been investigated and [we] currently await the final report.”

The Care Quality Commission recently carried out a routine, in-depth inspection of the hospital trust. A full report is due to be published this month.

As a matter of course, maternity services would be looked at in detail with CQC inspectors speaking to staff and patients. Any recent safety concerns raised with the CQC would also be looked at as part of the inspection visit, the regulator confirmed.

Readers' comments (3)

  • Concerns were investigated by former chief executive Nancy Hallett: I wonder if she can actually be correctly called an uninterested party? I thought investigations of this nature were supposed to be investigated by people with out any interest in the matter and no previous association with the dept in question too.

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  • The Truth about Homerton Hospital Maternity Unit

    The above article refers to concerns about patient safety raised by the unhappy midwives group (UM) to former Chief Executive Nancy Hallett and current CEO Tracey Fletcher from as far back as June 2012 to current.

    I’ve had the privileged opportunity of working with and where possible given advice to this group of genuine whistleblowing midwives. The UM are simply campaigning for a safer maternity unit and equality in their employment. As a very concerned member of the public, with a very good understanding of the concerning state of affairs within Homerton’s maternity department, I would like to respond in support of the UM group.
    As this is a matter of public safety and matters lying within the public’s interest, I feel bound to respond to this article. My delayed response is intentional as I felt that it was important to wait for the CQC’s report on Homerton Hospital- with particular interest in the maternity department. This report is now out.

    Follow link-
    http://www.cqc.org.uk/directory/rqxm1

    As you will see - the CQC gave Homerton’s maternity department a ‘Good’ rating. This is despite the CQC being supplied with overwhelming evidence of clinical incidents leading to harm and avoidable deaths of babies and mothers in the Homerton’s maternity department. Evidence indicates that the CQC did not review any of these clinical incidents. Which begs the question – How did the CQC arrive at the conclusion that the Homerton’s maternity unit is safe? – and more to the point - Can the public really believe that the CQC has been revamped and is of greatly improved standards as we’ve all been led to believe?

    The Unhappy Midwives (UM)

    The concerns of the UM surround a number of avoidable deaths within the maternity unit(services) and what they understand to be deep seated and entrenched racism within the maternity department - to such an extent that it affects patient care. Grave concerns were raised by the UM about a number of clinical incidents which the midwives believe led to the avoidable deaths of mothers and babies in their unit.
    Particularly, the midwives expressed concerns that a midwife in their midst is singularly linked to the death of four or more babies in a three year period yet this midwife continues to practice unchallenged, thus continuing to place patients at risk. Evidence suggests that such a shocking statistic relating to a single midwife is rare if not non-existent in the western world!
    Also, the UM raised concerns about the deaths of two mothers in their unit in less than 3 months (July-October 2013). Some of the UM’s concerns include the fact that certain midwives were directly involved in serious clinical incidents which led to harm and death of babies although patient safety concerns were previously raised about these same midwives.

    Please note that the UM’s concerns are in relation to their maternity unit only and have no bearings on the remainder of the departments within Homerton Hospital.
    Homerton’s Flawed Internal Investigation
    In response to the concerns raised by the UM in June 2012 - former CEO Nancy Hallett stated that she conducted an internal ‘investigation’ and concluded that the midwives concerns were ‘unfounded’. She proceeded to warn the midwives that if they continued to raise concerns on these matters the trust would ‘engage with the relevant authorities in pursuing action with regard to these’ and point blankly declared that she wanted no further contact from the UM. However, in Ms Hallett’s response to Diane Abbott MP about these grave concerns, she falsely stated that she offered to meet with the UM with an independent mediator.

    The UM informed Ms Hallett that they believed that her ‘internal investigation’ was flawed. Because of Ms Hallett’s threats they sought other avenues through which to raise their concerns. Follow link-
    See bottom of page for link to Email from UM to Nancy Hallett
    The City and Hackney CCG’s (C&H CCG) Commissioned Review into the UM’s concerns
    Faced with failures from their trust to acknowledge the grave conditions in their maternity unit, the UM brought their concerns to the CQC, the Department of Health, NHSLA, the London LSA, the NMC amongst other organisations. In July 2012 - the CQC failed to acknowledge or respond to the UM’s concerns.
    The City & Hackney CCG contacted the UM in May 2013 and subsequently offered to commission an investigation into their concerns.

    There have been a number of correspondences between the CCG and the UM over several months which shows that the UM were committed to patient safety and worked closely and cooperatively with the CCG lead. The UM facilitated a meeting between the CCG and an intermediary to further address their concerns. Thus, the CCG’s spokesperson statement as above, that ‘the CCG was contacted by an anonymous person or persons suggesting they are midwives at the Homerton University Hospital Trust claiming concerns about safety issues at the trust,’ seems wholly unfathomable.

    The UM were not satisfied with the CCG’s Terms of Reference for investigation into their concerns as they felt they were limited in their scope. They provided additional Terms of Reference to the CCG - but The CCG did not incorporate the UM’s additional terms into the investigation. The UM contacted the Department of Health with their concerns about the C&H CCG’s investigation.

    Follow Link-
    See bottom of page for link to
    Emails between UM and Dr Clare Highton (CCG Lead)
    C&H CCG Terms of Reference (ToR)
    UM’s suggested additional (ToR)
    Email from DoH to UM

    False Statements by HUH’S CEO- Ms Tracey Fletcher

    In the article above - in an extract from the trust’s report, Ms Fletcher falsely stated-

    ‘The trust has attempted to engage with the group and responded to their emails but to no avail and they remain anonymous.’ (Trust Board Meeting in September 2013)

    This statement was proven to be a blatant and deliberate lie by this CEO as there is evidence that six months prior to Ms Fletcher’s statement - the UM informed the CEO that they were willing to meet with her provided that certain conditions were met. Despite the trust Board receiving clear evidence of this false statement by Ms Fletcher, Ms Fletcher has made no attempt to withdraw her statement. Here is the evidence.
    Follow link-

    See bottom of page for link to
    Emails between Tracey Fletcher and UM AND
    Email to Chairman from UM

    The above linked emails prove that Ms Fletcher knowingly misled the trust and the public on this matter. The truth is - it is Ms Fletcher who failed to respond to the UM. I have no doubt that had this been a clinician, they would have faced disciplinary proceedings and most probably, hauled up before their regulatory council. The fear of retaliation and reprisal, and to prove that their concerns were genuine and not malicious - meant the UM felt it necessary to make this conditional request. This request entailed for the meeting to include a member of a police authority and others amongst the panel. Homerton’s CEO ignored this response but chose to make a false statement six months later to the trust board and the public that the UM failed to engage with the trust.

    Homerton CEO refers UM’s Patient Safety Concerns to NHS Protect- alleging harassment

    It is ironic that Ms Hallett, Homerton’s former CEO threatened the UM ‘to engage with the relevant authorities in pursuing action’ and Ms Fletcher referred the concerns of the UM to NHS Protect yet the latter CEO refused to respond to a request to meet with the midwives in the presence of these very same authorities that they relied on as basis for their threats. The trust’s referral of the UM’s patient safety concerns to NHS Protect under the premise of alleged harassment is disgraceful and utterly unacceptable. Not forgetting the strain on the public purse. This situation demonstrates clear evidence that Homerton Hospital does not encourage speaking out safely.
    Follow link -

    https://www.whatdotheyknow.com/request/reporting_of_whistleblowers_by_h#incoming-501012

    From the above FOI Request it can be seen that NHS Protect took no actions against the UM. And quite rightly so – the UM are raising patient safety concerns. Why should they be penalized for this? It appears that Ms Fletcher was quite keen to suppress these concerns hence falsely labelling them of being ‘vindictive’ and causing harassment.

    The City and Hackney CCG’s Flawed Review/Investigation

    The following information about the City and Hackney CCG (C&H CCG) is noteworthy-

    Dr Clare Highton (C&H CCG lead) has refused to acknowledge the concerns of the midwives about the investigation. Most notably, as I understand it - on 27th October 2013, at a meeting with an intermediary selected by the UM, Ms Maureen Brown (the lead investigating midwife selected by NHS England (NHSE) stated that she did not have any knowledge of the list of clinical incidents compiled by the midwives and sent to Dr Highton at her request since July 2013. This suggests that these clinical incidents were not passed on to be reviewed/investigated. By then, the review team had spent 3 days in the Homerton Hospital.

    What exactly was the external team (CCG lead midwife and team) reviewing/investigating?

    The UM expressed that Ms Brown was instead, focused on disproving racism in their unit despite investigations of this nature not falling within the remit of the CCG. Dr Clare Highton has failed to acknowledge or make any contact with the UM since their complaint to her in October 2013, despite the CCG’s review being commissioned into the UM’s concerns.

    See bottom of page for link to

    Emails between UM and CCG (Email 1)
    Emails from UM to Maureen Brown (Email 2)
    Emails from UM to Dr Highton (Email 3)

    Delays in the CCG’s Report

    There are grave concerns that this report remains outstanding. According to the response to an FOI directed to the CCG, this report was scheduled to be released in December 2013.
    Follow link-

    https://www.whatdotheyknow.com/request/city_and_hackney_ccg_investigati#incoming-462117

    However- in the article above, as of 9th April 2014, the CCG was still awaiting the final report. Most notably, it appears that this report has been tactically delayed until after the CQC inspection report on HUH.
    The delay in the provision of this report by CCG raises many unanswered questions. The fact that this investigation is surrounding the deaths of mothers and babies makes it all the more important and as such, severely delaying a report of this nature is unacceptable.

    It is believed that Homerton Hospital is hiding under the assumed credibility of an ‘external CCG investigation’. This particular investigation however has been fraught with flaws and failures right from the start. In the article above, the CCG state that the UM’s concerns were ‘thoroughly investigated’ by the trust and they are conducting this review to ‘assure [themselves]’. Thus, based on the CCG spokesperson’s comments above - it is safe to say, it’s a foregone conclusion that the City and Hackney CCG will find ‘no concerns’ within Homerton’s maternity unit and the outcome of the CCG’s investigation appears to be already predetermined. In light of the serious clinical incidents of concern, this is an exceedingly disturbing thought.

    I understand that during this lengthy wait for the CCG’s report - there have been serious clinical incidents that led to patient’s harm and death within Homerton’s maternity department. There are reported cases of further never events yet the CCG continues to delay with this report.

    THE CQC’s Intelligent Monitoring- Homerton Hospital Band 1 Risk Rating

    - In October 2013- The CQC’s Intelligent Monitoring System placed Homerton Hospital in the highest risk category (Band

    1). Follow Link-

    http://www.mirror.co.uk/news/uk-news/patients-at-risk-unsafe-care-2528136

    Does the HUH’s current favourable CQC report indicate that the CQC’s Intelligent Monitoring System is not that ‘intelligent’ after all? The HUH is seen to have moved from the Highest risk banding (Band 1) to a very favourable position. This doesn’t make any sense at all.

    The CQC’s Reliance on City and Hackney CCG’s Flawed Investigation

    After experiencing failures with the CCG’s flawed investigation and after Dr Highton’s refusal to acknowledge or respond to the UM’s concerns - the UM decided to contact the CQC once again.

    The UM decided to give the CQC a chance to rectify their previous failures in acknowledging their concerns. And they decided to offer to meet with the CQC in order to voice these concerns with the hope that they would be finally addressed. This request was met with silence despite an initial response that CQC Compliance Inspector would contact the UM with regards to a meeting.

    Evidence of communication between Michelle Golden, CQC’s Compliance Inspector and the UM indicates that the CQC simply ‘raised the issues’ the UM brought to their attention ‘with the trust’, albeit the fact that these ‘issues’ include serious clinical incidents leading to severe harm of patients. In their recent inspection, the CQC did not review the clinical incidents of concern identified by the UM - as they were assured by Homerton that these incidents were being reviewed by the CCG (flawed investigation).

    So, if the CQC did not review these clinical incidents of concern, how can the CQC say they ‘found no evidence to substantiate’ the UM’s ‘allegations’? There are so many unanswered questions around the CQC’s investigation of Homerton’s maternity unit. The evidence suggests that CQC was not as thorough in their inspection of Homerton’s maternity unit as they would have the public believe.

    The CQC Inspection of Homerton Hospital
    There is evidence to prove that the CQC and Michele Golden CQC’s Compliance Inspector were informed by the UM of the following-
    • The complete list of clinical incidents that resulted in what the midwives believe to be avoidable deaths in the maternity department. (After the UM lost confidence in the CCG’s flawed investigation).
    • The blatant lies of the HUH CEO’s regarding the UM.
    • That certain midwives in the maternity department were coached and planted by maternity managers on exactly how to respond to CQC inspectors.
    • That certain staff (vocal midwives) were blocked (unexplained changes to rota or shift) from speaking to CQC Inspectors.
    There is evidence of the following-
    • The CQC failed to facilitate the UM’s initial request to meet with them.
    • Michele Golden (CQC Inspector) only decided to invite the UM to speak about their concerns on leadership after HUH was inspected by the CQC team and given a preliminary favourable result. The UM informed Mrs Golden that this was unacceptable as the CQC failed to honour their initial request to meet and they believed that any meeting with the CQC at that late stage would come across as retaliatory.
    • The UM referred Mrs Golden to make an assessment on leadership by assessing the vast amount of evidential documents that they provided to the CQC in July 2012 and over the past months. They made specific reference to certain evidence proving that their main leader (Tracey Fletcher) lied and misled the public and the trust. As such, the UM stated to the CQC that the evidence provided by them shows poor leadership from the top downwards. The UM believe that they were failed by the CQC once again. Please judge for yourselves. Follow Link-

    See bottom of page for link to
    Email from UM to Michele Golden (CQC)
    Email from Michele Golden to UM
    Email from UM TO Michele Golden

    The Belief that CQC has Failed the Public
    It is believed that it is in the CQC’s best interest that HUH maternity was given a ‘Good’ rating as Homerton has been given the green light in past inspections due to failures on their part (CQC). The CQC was contacted about patient safety concerns by the UM as far back as July 2012 and they took no action whatsoever. There have been a number of preventable tragedies at Homerton’s maternity unit between the period from which the UM contacted the CQC to present. Thus, I believe it is in the CQC’s interest that Homerton maternity unit is given a ‘good’ rating as anything less would implicate the CQC and render them accountable and culpable for these tragedies.

    Follow Link-

    https://www.whatdotheyknow.com/request/patient_safety_concerns_racism_a_2#outgoing-296576

    By giving Homerton’s maternity unit a ‘good’ rating, I strongly believe that the CQC has provided false reassurances to the public at large.

    This bears certain similarities to CQC’s actions at Furness General Maternity Unit.
    With reference to Furness General the CQC is quoted as saying-

    "The report shows how CQC provided false assurances to the public and to [healthcare regulator] Monitor in 2010. We were slow to identify failings at the trust and then slow to take action. We should not have registered UHMB without conditions. We let people down, and we apologise for that."

    Follow link-
    http://www.theguardian.com/society/2013/jun/19/cqc-nhs-cover-up-maternity-ward

    The London Local Supervisory Authority (LSA)
    As part of their patient safety campaign - the UM contacted the London LSA and offered to arrange a meeting with them to discuss their patient safety concerns. The LSA is responsible for ensuring the statutory supervision of all midwives. However the LSA too were waiting on the outcome of the CCG’s investigation.

    Follow Link-

    See bottom of page for link to
    Email between UM and LSA

    Conclusion

    Maureen Brown - the selected midwife leading the CCG’s commissioned review had no knowledge of the clinical incidents of concern despite the incidents having been submitted by the UM to the CCG via Dr Clare Highton (CCG Lead) several months earlier. On the other hand, the CQC has given these clinical incidents a ‘wide berth’ as they have been assured by Homerton that the incidents are being reviewed under the CCG’s commissioned review, (7 months on)!

    What does this say to the public about the review of these clinical incidents of concern and the exact state of affairs within Homerton’s maternity? Were these incidents reviewed - if at all? This seems to be a complete and utter cover up of the truth!
    It is believed that failures by certain organizations to act or respond in time to patient concerns raised by the UM, means that additional harm to patients could have quite possibly been prevented. Because of this reason - I believe the organizations in question have either remained silent or have responded in favour of HUH in what appears to be one of the biggest cover-ups in the NHS today.

    A CEO who reports whistleblowers to NHS Protect and a predecessor who threatens to engage with the relevant authorities in pursuing action against them – Can one honestly say that Homerton Hospital supports speaking out safely? My answer to this is a resounding NO!

    The public would be shocked to learn the details of the clinical incidents of concern. This would explain the reason why the CCG’s terms of reference as above, include sharing the report with the ‘stakeholders upon completion’. To the contrary, the UM suggested that the report to be shared with the public. It is no surprise then that City and Hackney CCG failed to take on board the UM suggestion. Judging by the perceived cover- ups and the flawed investigations, I suspect that the details of the clinical incidents contain information which Homerton does not want the public to know.

    Over the weekend of 26th -27th April 2014 – I understand that another mother died at Homerton Hospital maternity department. This is the 4th maternal death linked to Homerton’s maternity in approximately 9 months. My deepest sympathy to the family of this mother who has lost her life.

    With the evidence provided - can one be truly confident that the CQC gave the correct grading to Homerton maternity unit? My answer to this is also a resounding NO!

    Please follow link below for more information
    http://wp.me/P4A9w0-g

    Unsuitable or offensive?

  • errolking69

    It is impressive what UM have tried to do, and I commend them and you. But it must feel as though you are beating your head against a brick wall, my heart goes out to those Midwives.

    Racism was endemic in that unit even in the days when it was Mother's hospital.
    That it is no better now is no surprise to me that would take insight and this is very lacking in the management of HUH as a whole.

    What does it take for this to become a "Stafford Hospital event" and have the whole thing investigated effectively and dealt with?

    In the meantime mothers, without any choice of where they deliver, will just have to hope for the best! And accept what ever HUH serves them, good bad or indifferent.

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