Homerton maternity whistleblowers, FOI disclosure of the London Clinical Senate report on four maternal deaths and the National Guardian



By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist 28 September 2016

Black whistleblowers, including the ‘Unhappy Midwives’, have been raising concerns about maternity service safety and racism at Homerton since 2012, but have been vilified and marginalised. Their appeals to the trust and oversight bodies, including Jeremy Hunt, the Department of Health and the Care Quality Commission – the latter rated the Homerton service ‘Good’ in 2014 despite the whistleblowers’ evidence – fell on deaf ears. This was followed by a cluster of maternal deaths from 2013 and onwards.

Extensive audit trail of the midwives’ whistleblowing and correspondence is collated at this website:  https://homertonnhsmaternity.wordpress.com/

Their case was covered by Private Eye in September 2015:  http://www.drphilhammond.com/blog/2015/09/23/private-eye/medicine-balls-private-eye-1341/

The maternity whistleblowers were ignored and their concerns were minimised, including by the Clinical Commissioning Group and Care Quality Commission (CQC). Two successive Chief Executives vilified the ‘Unhappy Midwives’, and the current CEO deemed them “vindictive”. [1] The Department of Health, as per its usual response to whistleblowers, did its best to wash its hands of the matter and directed them back to the CQC.

At least 5 maternal deaths – usually very rare events – occurred after the midwives were ignored. There was extensive press coverage. For example, by the Daily Mail:



Under pressure, the trust eventually commissioned an external review by the London Clinical Senate into four of the maternal deaths. An incomplete copy was disclosed via FOI in October 2015 – senate-report-redacted-for-patient-confidentiality – but nevertheless, it showed that the Senate had concluded that there were ‘avoidable factors’.

The midwives remain concerned, and are not convinced that the trust has disclosed all relevant information about its maternal deaths, some of which occurred at surrounding trusts.

Homerton trust informed me that a total of 7 mothers died under its care between 2006 and October 2015. The midwives question whether this is an accurate figure. Nonetheless, it is noteworthy that the trust has admitted that 6 of the 7 mothers who died were non-white. [2]

Ten years ago, when the CQC’s predecessor investigated a cluster of 10 maternal deaths at Northwick Park, 9 of the 10 women were Black [3] :


Unlike the Homerton trust, the Healthcare Commission published its report in full and without redacting key clinical details that were essential for full transparency and learning. It is a concern that the trust seeks to protect itself by witholding the full Senate report, purportedly because of ‘confidentiality’.

The NHS acknowledges that for a variety of reasons, BME mothers remain at higher risk of harm. Surely it is time to mitigate these known risks and expect greater equality of health outcomes, rather than just continue wringing hands?

However, the NHS is notorious for its ‘snowy peaks’, and it remains poor on monitoring and delivering equality of outcomes. It is also of concern that the Homerton trust board is wholly white, when it serves one of the most deprived and racially diverse catchments nationally.


A Subject Access Request for personal data was made by one of the whistleblowers, Pam Linton, who originally raised her concerns independently of the Unhappy Midwives. The resulting disclosure by CQC has raised serious questions about the CQC’s response to Pam Linton’s disclosures. [4]

And in case you didn’t know, Henrietta Hughes CQC’s recently appointed National Guardian for whistleblowing, was the NHS England area medical director party to the multi-agency response to the Unhappy Midwives’ disclosures. She starts at CQC very shortly, in October. Questions have been asked about her role in the Homerton matter, but with no clear answers arising.

Henrietta Hughes will report to David Behan, Chief Executive of the CQC. That is, the CQC which superficially reviewed itself in regards to its handling of Homerton maternity safety,  but which has not fully acknowledged its failures. [5]

What a small world.

And what a cosy example of the “circular assurance” described by Bill Kirkup in his report of patient safety failings at Morecambe Bay. [6]


The City and Hackney Clinical Commissioning Group records which show that Henrietta Hughes was involved in the system response to the Unhappy Midwives:

Click to access Q2%20NHSE%20Assurance%20Compiled%20Exception%20Reports%2029112013.pdf



Items to cross-reference

Letter to Jeremy Hunt Secretary of State for Health about his and the Department of Health’s role in the failure of the system response to the Unhappy Midwives


How the National Guardian’s office is designed to be ineffective:



[1] Homerton safety review after claims from ‘unhappy midwives’, Jo Stephenson, Nursing Times, 9 April 2014


[2] FOI disclosure by Homerton University Hospital NHS Foundation Trust 24 February 2016

[3] Investigation into 10 maternal deaths at, or following delivery at, Northwick Park Hospital, North West London Hospitals NHS Trust, between April 2002 and April 2005, Healthcare Commission August 2006 hcc-northwick-park-_tagged

[4] CQC response to a subject access request by Pam Linton pam-linton-294593874-cqc-sar-disclosure-1

[5] CQC internal review of CQC’s handling of Homerton maternity safety, 15 March 2016

Click to access CM031605_Item_5A_RGC_Report_to_March_Board_FINAL_Appendix_1.pdf

[6] The report of the Morecambe Bay investigation, Dr Bill Kirkup, March 2015

Click to access 47487_MBI_Accessible_v0.1.pdf


Disclosure correspondence from Homerton trust

From: Dunne Michael at Homerton University Hospital NHS Trust <Michael.Dunne@homerton.nhs.uk>

Subject: FOI Request 2108 – Homerton Maternity Services: Report of Review by London Clinical Senate

Date: 27 October 2015 at 16:09:00 GMT

To: minhalexander@aol.com

Dear Dr Alexander,

Thank you for your recent Freedom of Information request, asking for a copy of the London Clinical Senate report.

Please refer to the attached documents which includes the Trust’s formal response along with a redacted version of the report.

Yours sincerely,

Mike Dunne

Information Governance Manager & FOI Lead





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