Thousands of followers of this website may remember last year’s nine blog coverage I gave to the employment tribunal over the sacking of whistleblower Mr Martyn Pitman at Hampshire Hospitals NHS Foundation Trust (HHFT). He lost the hearing. He was belittled and and repeatedly insulted by the former head of chambers, Mark Sutton of Old Square Chambers, including calling him a ‘freelance agitator,’ only to later be forced to retract that slur. Sutton, who picked up a big share of the £650,000 taxpayer funded legal fees pay out to represent the trust, approached the ET by portraying Mr Pitman as something of a tyrant, an assessment clearly not shared by his previous colleagues, who actually worked with him, attending in numbers at the hearing, or indeed by his thousands of social media supporters
Mr Pitman was sacked because it was said his employment there was ” a present danger to patient safety ” by the former chief medical officer of the trust, Lara Alloway. It was also claimed that his relationship with the Trust’s senior management had ‘irretrievably broken down”. Yet it was he who had raised patient safety issues which was stomped on by non-clinical senior midwifery managers, despite identical concerns also being raised a few months later by several senior clinical midwives.
Well now a year on, following Mr Pitman’s dismissal, it is revealed that there is a ” present danger to patient safety ” in the maternity wards at the trust – a more than five fold increase in the number of babies delivered there with labour-related hypoxic brain injury (Hypoxic Ischaemic Encephalopathy: HIE) many of which may have been preventable. According to the Trust’s latest on-line patient information approximately 5,700 babies are delivered across its 3 sites.
The trust had an extremely low rate of HIE until now
In the final year of Mr Pitman’s Consultant tenure at HHFT, prior to his formal dismissal, the HIE rate across the Trust was reported as 0.5 per 1000 deliveries – equivalent to less than 3 babies per annum. In 2023, the year following his dismissal, the rate increased, in a previously unprecedented fashion, to 2.5 per 1000 deliveries, equivalent to 14 babies per annum.
Of course the trust dispute this – even though it was published in a very thorough article by Sirin Kale for Guardian Society. The full article is well worth a read and you can link to it here.
The trust communications department described the article as misleading. A statement said:
“There are instances in Ms Kale’s reporting where we believe her reflection of the facts is misleading. This interpretation of the data fails to provide the reader with the wider context required to understand it. It therefore runs the risk of unreasonably undermining public confidence in a service which is safe and performing well. To avoid misleading the public we would strongly suggest that your article must explain that the rate of HIE in live births with Hampshire Hospitals is well within the normal limits.”
I might have believed them but for an internal power point presentation at a clinician led Neonatal Morbidity and Mortality meeting held at the trust in February. Reproduced below it says precisely the opposite to what the communications department is claiming – that cases of HIE are ” significantly worse than the network average”. It also proposes tough action to combat it. If people are to believe there is no problem and everything is safe – such action speaks volumes.
This particular issue at the trust was one of the problems raised by Mr Pitman in 2019 when he made his whistleblowing complaint in early 2019.
He told me:” I had a specialist interest in fetal monitoring, CTG interpretation and labour management optimisation. Throughout my period of tenure I was responsible for cross-site staff teaching of fetal /CTG monitoring and had developed a regional reputation for my expertise in this area. For several consecutive years I had been praised for playing a significant role at RHCH in minimising the HIE rates down to commendably low levels well below the network and indeed national average for 2 consecutive years. For instance, we achieved the enviable statistic of not having a single poor maternity outcome attributed to CTG misinterpretation. This dramatic deterioration, in a critical maternity outcome metric, that I was passionate about and had successfully devoted my focus and clinical attention to, to have occurred within the 12 months since my dismissal will certainly not have escaped the attention of either the senior midwifery managers or the Trust’s senior management.”
Indeed significant events back in 2019, that led to Mr Pitman’s formal investigation and eventual dismissal included a a dispute between him and the midwifery managers about the dangers of sub-optimal fetal monitoring, including the potential pitfalls of assessing the baby’s heart rate using hand-held dopplers (intermittent auscultation) and confusing the baby’s heart rate with that of the mother.
He told me:” I was concerned that deteriorations in the standard of fetal monitoring and, particularly midwifery complacency in this regard in what were thought to be low-risk mothers was a developing concern and that if it was not addressed would lead to worse outcomes and, potentially increased baby injury (HIE) and death rates. This warning was completely and utterly ignored by the senior midwifery management. ” Such concerns have been highlighted repeatedly in other units across the UK, including the recent reviews undertaken by Donna Ockenden”.
What he predicted and was striving to prevent, by making practice recommendations, in the April 2019 Fetal Monitoring Guideline meeting has now happened. Instead of supporting him moves were made to silence him and to get him out of the way.
He said: “The very evening after this, unusually confrontational and adversarial, guideline meeting was when I was first ‘invited’ to a meeting which eventually developed into my formal disciplinary investigation. The senior midwifery managers had decided that my attempts to prevent their dangerous normalisation agenda had to be stopped
Two terrible baby births at Winchester hospital
Worse then happened, within just a week of this fateful meeting. As well as the tragic case raised in Sirin Kale’s article distressing case, where a baby was deprived of oxygen throughout labour and delivery . This second baby was delivered within just hours of the case featured in Sirin Kale’s Guardian article. Mr Pitman was the Consultant on-call in the Winchester Maternity Unit when both these tragic cases were delivered but, as they were midwifery-led, as they were believed to be ‘low-risk,’ neither he nor the Obstetric team had been directly involved in their care, until the ‘crash-calls’ were put out.
He said: a ” supposedly entirely low-risk healthy baby, maintained under solely midwifery-led care, was born moribundly unwell from HIE and needed to be urgently transferred to Southampton Hospital for brain cooling. The Head of midwifery, my principal complainant, who had been in the guideline meeting would have come into work the following Monday, been informed of these 2 cases, that there were huge issue with the intrapartum monitoring of them both, realised that this put her in a challenged position and given my concerns and the practice changes that I had been recommending just the previous week. This appears to have prompted her to escalate her concerns about me into a formal complaint, rather than an issue that could and should have been addressed by mediation. The timeline of events, at this time, was very telling”
So where does leave the maternity services at Winchester and Basingstoke hospitals? The trust has been on a public relations drive inviting the local BBC TV station, BBC South, into the maternity wards BEFORE it published these worrying figures on babies delivered with HIE. This was arranged and was broadcast less than a month before the concerning increased HIE rates were presented.
Here’s a video of the report:
Since then the trust has promised an internal , rather than , perhaps far more appropriate, independent external inquiry – rather the same philosophy as the Post Office used to say their Horizon computer project was sound when sub postmasters were being jailed for false accounting.
The most tragic outcome is that there are potentially parents in Hampshire who face a lifetime of worry worry and expense caring for children, who may have suffered avoidable labour-related hypoxic brain injuries. One also has to wonder what the level of medical negligence claims associated with these cases could, potentially, extend to? This could have been prevented if the trust was doing its job. Given the state of social care in this country this is a very serious state of affairs. You cannot say the trust were not warned by Dr Pitman. The then interim chief medical officer was Dr Nick Ward, a consultant paediatrician whose expertise is in paediatric nephrology.
So does the top management carry some blame? I put it to the communications department that Alex Whitfield, Lara Alloway ( now CMO at Hampshire and Isle of Wight Integrated Care Board), the midwifery management team, and Steve Erskine, chair of the trust board did. I got no comment on this but given what appears to be their complacent attitude to what is happening there I really wonder whether they do care about anything except the trust’s reputation.
On May 2nd one of the foremost experts on inquiries into maternity care Mr Bill Kirkup, has been invited to give a lecture at the trust. He has investigated baby deaths in the Morecambe Bay Trust and in the East Kent Trust. I wonder what my former colleague on the Gosport War Memorial Hospital independent panel will have to say about the Hampshire Hospitals NHS Foundation Trust.
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