BY EMAIL ONLY
To Rt Hon Jeremy Hunt Secretary of State for Health, 16 October 2015
Dear Mr Hunt,
Re: Maternal deaths and the safety of Homerton maternity services
I understand that anonymous Black midwife whistleblowers, who call themselves the “Unhappy Midwives”, contacted you personally in July 2013.
As you should be aware, the Unhappy Midwives first made disclosures to both Homerton University Hospital NHS Foundation Trust and to CQC in 2012, about poor care and Race discrimination that impacted on patient care and safety. They did not feel their disclosures were appropriately acted upon by either the Trust or by CQC. A series of at least 5 maternal deaths then followed, starting in July 2013.
The Unhappy Midwives made exhaustive attempts to warn all those in positions of responsibility about the fact that their safety concerns were unresolved, and about their concern that both internal Trust investigations and a review by the Clinical Commissioning Group (CCG) were seriously flawed. For their pains, the Unhappy Midwives were branded “vexatious” and “vindictive” by two successive Trust CEOs, and threatened with various forms of punitive action.
I understand that the Unhappy Midwives wrote to you personally in July 2013 after the first Homerton maternal death. I believe they warned you in some detail of their concerns about:
- Risks to patients’ safety
- Race discrimination affecting both staff and patients
- Serious reprisal against a named Black whistleblower in Homerton maternity services.
- Homerton’s apparent failure to disclose a particular midwife’s poor safety record, of baby deaths, to a subsequent employer.
However, the Unhappy Midwives’ correspondence was passed to your officials, who I believe fobbed them off and eventually directed them back to the very bodies about which they were concerned. I also believe that there was no help from you personally or from DH officials for the named whistleblower, despite a request from the Unhappy Midwives that you urgently help this person.
Moreover, the Unhappy Midwives explicitly warned DH officials of serious flaws in the CCG’s review of Homerton maternity services, and also their concern that the Trust was intimidating staff to prevent them from giving truthful evidence to the CCG review. However, I now see that DH officials are citing the CCG review report as assurance data. DH officials are also wrongly claiming that this review did not in any way substantiate the Unhappy Midwives’ concerns, when a cursory examination would show that it very clearly did. Most importantly the CCG review validated the Unhappy Midwives’ concerns that the Trust was not learning enough from serious patient harm, and was not making links between serious incidents.
As I think you know, at least four more Homerton mothers died after you and DH were informed of serious flaws in the governance of the Trust and CCG.
Maternal deaths are normally rare events. The clustering of deaths at Homerton prompted yet another review last year. The London Clinical Senate carried out this review, but the Senate report appears to have been withheld by the Trust and CCG. The Trust CEO suggested in a recent internal email that the Trust would most likely continue withholding the Senate report. This clearly flies in the face of Dr Bill Kirkup’s recommendation 25 that NHS bodies should not be allowed to withhold the findings of external reviews.
I should note that in addition to maternal deaths, the Trust has now disclosed under FOI that there have been 20 intrapartum deaths, stillbirths and neonatal deaths since 2012. There have also been 2 Never Events, and a total of 79 serious incidents since 2012. There is also concern that other harm has occurred due to staff with unsafe practice moving to other organisations.
Despite the concerns about how the Trust has treated whistleblowers and handled safety in maternity services, I see that you continue to publicly praise the Trust CEO for value-based leadership and for listening to staff.
A question arises about failure by you, DH and arms length bodies to sufficiently protect mothers and babies, despite the repeated warnings.
Accordingly, I would like to understand how you and the Department of Health have handled this matter.
There is a particular need for transparency because of the concerns of Race discrimination, the harm to BME patients and the evidence from the Freedom to Speak Up Review that BME whistleblowers are more likely to be ignored and victimised. I ask you to note that in a very high diversity area, the “Snowy Peaks”  of the Homerton Trust board are wholly white.
1) All communications between Homerton University Hospital NHS Foundation Trust and you, and DH, from July 2013 onwards, regarding the safety of Homerton maternity services, including the handling of any whistleblowers’ concerns.
2) All communications between City and Hackney CCG and you, and DH, from July 2013 onwards, regarding the safety of Homerton maternity services, including the handling of any whistleblowers’ concerns.
3) All communications between Care Quality Commission and you, and DH, from July 2013 onwards, regarding the safety of Homerton maternity services, including the handling of any whistleblowers’ concerns.
3) All communications between NHS England and you, and DH, from July 2013 onwards, regarding the safety of Homerton maternity services, including the handling of any whistleblowers’ concerns.
Please include letters and emails, and appended documents.
It seems to me that the culture of “circular assurance” described by Dr Bill Kirkup still flourishes, in that the DH and its arms length bodies are far more inclined to listen to each other and NHS organisations, than to listen to dissenting voices.
I would like to remind you of the calls over the years for safe harbour and a truly independent body for whistleblowers, including a recent call by Simon Stevens on behalf of NHS England. I believe the Homerton saga is another tragic, wasteful story that plainly illustrates why such a body is needed.
Dr Minh Alexander
 The “Snowy White Peaks” of the NHS: a survey of the discrimination in governance and leadership and the potential impact on patient care in London and England, Roger Kline, Middlesex University 2014
cc Rt Hon Dame Margaret Hodge MP Barking
Diane Abbott MP Hackney North and Stoke Newington
Meg Hillier MP Hackney South and Shoreditch
Shadow Secretary of State for Health
Public Administration and Constitutional Affairs Committee
Public Accounts Committee
Sir Peter Bottomley MP
Rt Hon Sir Anthony Hooper
Sir Robert Francis QC
Professor Sir Bill Kirkup
National Maternity Review
An update on the Homerton maternity whistleblowers 28 September 2016
A copy of the London Clinical Senate report on four maternal deaths is provided.