Father whose baby died due to errors by Lincolnshire Hospitals NHS Trust says lessons must be learned

A father who lost his son following negligence at Lincoln County Hospital has expressed disappointment, saying “lessons have not been learned”, after a CQC report recommended that the United Lincolnshire Hospitals NHS Trust (ULHT) should return to ‘special measures’ following the latest inspection.

The Trust exited the special measures regime in February 2015 following a temporary improvement in safety standards. However, recent findings suggest that “these improvements have not been sustained and there has been an overall deterioration in quality and patient safety”.

Rolf Dalhaug’s son Thor died in 2013 due to preventable events at Lincoln County Hospital.

At an inquest into Thor’s death, the senior coroner for Central Lincolnshire ruled that Thor died an hour after birth from fatal brain damage due to errors by medical staff. The inquest report found that an unsupervised junior doctor used forceps in an ‘unorthodox and unacceptable’ way to deliver Thor.

The coroner found that the investigation into the cause of Thor’s death was inadequate and on that basis issued a Prevention of Future Deaths Report to ensure that the Trust addressed systemic failures.

Within the Trust’s response to the coroner’s report, various assurances were given such as that the Trust were implementing measures to improve supervision, record keeping and investigatory practices.

The Chief Executive concluded the Trust’s response by stating:

“I would like to conclude by repeating my apology for the substandard care that led to Thor’s death and for the subsequent poor governance that hampered your investigation and clearly caused significant additional distress for the family. This is a matter of great regret. Whilst I know that the actions taken cannot bring Thor back I hope you and the family will be reassured that the Trust has put important changes into place. I would like to apologise for the difficulty the family have faced during this process, but the Trust does and will continue to strive to provide the best care it can for the community it serves.”

Less than two years on, in April 2017, the CQC has concluded that maternity services require improvement because, amongst other things:

• Staff did not demonstrate learning from audits such as CTG audits or post-partum haemorrhage audits.
• The maternity dashboard data was not utilised fully. The data lacked red amber and green rating, which meant that staff could not assess the data against trust targets.
• Staff did not receive regular recovery training and only 51% of health care assistants had received training in basic life support.
• The lack of a dedicated elective caesarean section operating teams meant that in the event of an emergency patient’s surgery would be delayed.

Although liability for Thor’s death was admitted by the Trust shortly before the inquest in December 2014, it has taken an additional two years for the Trust to settle the civil claims brought on behalf of Thor’s parents by Suzanne White and Emma Kendall from the clinical negligence team at Leigh Day.

Suzanne White, from the clinical negligence team at Leigh Day, who represented Thor’s parents, said:

“It is truly alarming that the lessons from Thor’s death do not seem to have been learned, there was a very clear narrative verdict at his inquest and assurances given to his parents, however, just a couple of years later and there still appears to be problems within this Trust.”

Emma Kendall, who assisted on the case added:

“The settlement achieved on behalf of our clients was quite exceptional for its kind. We believe this was an acknowledgment of not only the tragic circumstances of the case, but also the gross failure by the Trust to discharge its’ duty of candor following the initial investigation process.”

Rolf Dalhaug said:

"Losing your child is probably the hardest thing any parent has to endure. The aftermath is horrific. All you hope and dreams shattered in an instant. Your life is changed forever, and the last thing any bereaved parent wants to do is fight for the truth.  

“Since the inquest and the shocking revelations as reported in the Coroners Prevention of Future Deaths Report, I have been keen to ensure the ULHT learnt from the circumstances of Thor’s death and its subsequent failure to investigate it.

“I was therefore very disappointed that ULHT has been put back into special measures. The CQC report highlights some very basic failures which echo themes from Thor’s death and investigation.

“I can only hope that the board and management take responsibility and strive to make essential and lasting steps to ensure patient safety and save lives.

“Without the compassion and professionalism of Suzanne, Emma and the rest of the team, we know this process would have been even harder. We’re doubtful that we would have ever found the truth surrounding Thor’s death, and the subsequent failures by the Trust, without them. We will always be grateful.”