Category Archives: Professionals

A loss of personal continuing care. 700 practices in 5 years. Is the GP going the way of the Dodo in the past, or the Salmon in the future? We need to rediscover it’s value.

GP numbers are falling (Trends in the NHS) , and over 700 practices have closed in the last 5 years. This means that list sizes are rising. This information dates to 2015, so is 2 years out of date. The rationing of places at Medical School, over 30 years and 8 administrations is to blame, along with poor selection age.

An example of a table of data is from Wales: 

In Wales there are 454 Practices, which consist of 1663 GPs, 334 other GPs (assistants), 3,187,000 patients, 7021 average patients per practice, and a residential population 3,099,000. This gives an average population per practice of 6826.

There are several issued hidden in these figures. There are more patients registered with Welsh GPs than there is population in Wales. This is because of the border issues, where patients in Wales get free prescriptions, but those eligible in England pay. There are many more part time GPs than there were 10 years ago. The figures, in rough terms, just have to be multiplied by 20 for England, and by 2+ for Scotland as the whole UK is under doctored.

The number of GPs up to 2011 is shown here (Nuffield Trust), but is of course 6 years out of date.. It is interesting that even professional reporters cannot find up to date comparison figures from the UK Regions to compare with England, and this emphasises that we have no “National” in our health services. There have however been consistently more GPs in Scotland

Another problem is the definition of a GP. WONCA had a go in 2005. Many different countries have many different interpretations. In the UK he has to be “Competent and Capable” (RCGP), able to work “Independently” and traditionally to provide continuity of care for families. This “cradle to grave” image is fast disappearing, and the reality of part time GPs who may not know their patients has to be faced. Is the GP going the way of the Dodo in the past, or the Salmon in the future?

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Laura Donelly and Patrick Scott reports in the Telegraph 16th October 2017: Rise of the ‘super-size’ GP surgery as quarter of practices now deal with more than 10,000 patients

New figures reveal the rise of the “supersize” GP surgery, amid the closure of almost 700 practices in five years.

Family doctors said they were being forced to handle far more cases than they could cope with, with one in four practices now seeing more than 10,000 patients.

The proportion of surgeries with such list sizes has risen by 27 per cent since 2013, the NHS data shows.

It follows admissions from the Health Secretary that the traditional family doctor role has been eroded by decades of underfunding.

Jeremy Hunt told a conference on Thursday that the “magic” of general practice was under threat, with GPs burned out and left feeling “stuck on a hamster wheel” with up to 40 patients to see daily.

The statistics from NHS Digital show that 28 per cent of GP practices in England have a list size of at least 10,000 patients – including some with more than 20,000 cases on their books.

Professor Helen Stokes-Lampard, chairman of the Royal College of GPs, said family doctors were left overloaded, and too often unable to meet the needs of their patients.

It follows admissions from the Health Secretary that the traditional family doctor role has been eroded by decades of underfunding.

Jeremy Hunt told a conference on Thursday that the “magic” of general practice was under threat, with GPs burned out and left feeling “stuck on a hamster wheel” with up to 40 patients to see daily.

The statistics from NHS Digital show that 28 per cent of GP practices in England have a list size of at least 10,000 patients – including some withmore than 20,000 cases on their books.

Professor Helen Stokes-Lampard, chairman of the Royal College of GPs, said family doctors were left overloaded, and too often unable to meet the needs of their patients.

She said: “The phenomenon of growing patient numbers, and a lack of GPs to deal with growing demand is a long-running trend, and something the College has been drawing attention to for many years.

“As a result, many GP practices are seeing escalating patient lists they they simply can’t deal with – although we must recognise that sometimes increasing list numbers are due to practices merging and pooling their resources,” she said.

Prof Stokes-Lampard said there was a desperate need for more GPs and practice staff.

Dr Richard Vautrey, GP committee chairman said doctors were struggling to cope with an extra 2.6 million patients registering in the last four years, while funding and staffing levels had not kept pace.

“GP services are struggling to cope with unsustainable workload and deliver the care their local communities need,” he said.

A recent BMA survey found that more than half of GP practices were considering closing their patient lists as they could no longer provide safe care to the public.

The figures show the total number of practices registered with a GP has risen from 56.2m to 58.7m in five years. Meanwhile the number of practices fell from 8,032 to 7,358.

Of those, 2,082 have more than 10,000 patients on their books – including 157 with more than 20,000 patients.

On Thursday Mr Hunt said many GPs were at the ‘end of their tether’ and dropping out of the profession. He said: “Too many of the GPs I meet are knackered, they are often feeling at the end of their tether.

“They feel that they’re on a hamster wheel of 10 minute appointments, 30 to 40 every day, seem never ending.

“They don’t feel able to give the care that they would like to to their patients and increasing numbers of them are choosing to work part-time and at worst to leave the profession.

“We have to think really hard about how to stop that happening if we’re going to use the magic of general practice to do what we need it to do for the NHS.”

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The decline of General Practice.. Bribes may be too late…

There will be many post mortems once the old fashioned GP has disappeared, but it is not only about numbers, but also about experience and reduction of waste. A good GP reduces unnecessary referrals and investigations, lives with uncertainty and is trusted to use time as a diagnostic tool. 20 years ago most countries envied our primary care GP system of gatekeepers, but we have steadily destroyed it. In Folkestone, (and many other places) the population is in dire need. The goose that laid the golden egg for efficiency has gone… Perhaps readers should ask their MPs 1: “Why have 9 out of 11 applicants for Medicine been rejected for 30 years, when we continue to import so many doctors from overseas? 2: “Why are 80% of Medical students women, and should this be addressed by graduate entry, or adverse selection. The answers are short termism and rationing.

In the last week I have heard and witnessed two stories close to me. A citizen had renal colic and was getting  better when seen at home. After 8 hours in Casualty, an USS, a CAT scan and bloods as well as urine dip test (not available to the paramedic visiting) he was sent home. The other was a case of acute orchitis who had 3 courses of antibiotics, investigations ++ and 6 consultations in A&E and GP. An experienced GP would have dealt with both these cases much more efficiently.

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Shane Brennan interviews Dr for the Daily Post 19th September 2017: The North Wales doctors surgery … with no doctors

Reliance on locums since GPs retired means some days there are four available, but some days only nurses

Nurses are having to stand in for GPs at a surgery where on some days there are no doctors available to see patients.
The Pen y Maes medical centre in Wrexham is being run by Betsi Cadwaladr since its doctors retired last year.

The health board has had to draft locum GPs in to do the work, but according to local councillors and patients, on some days there are none available.
Fed up patients are now planning a protest to voice their frustrations with health board bosses, who say they are looking to recruit GPs to take over the practice.
Councillor Gwenfair Jones, who represents Gwersyllt West – one of the wards hit by the problems at the surgery – said: “Despite repeated requests we are not getting the service that we deserve, a total reliance on locums means that some days there are four GPs other days there are none.”

She added: “The Health Board is meeting this Thursday at 10am at the Catrin Finch Centre at Glyndwr and we will be there to give them a warm welcome and to make sure patient’s voices are heard”
Dr Sophie Quinney from campaign group GP Survival (Wales) welcomed the protest, she said: “Patients are absolutely right to be concerned by the direction of travel for primary care across North Wales. It is well accepted that surgeries run by family doctors are more cost effective and for the most part deliver a superior service to those run by administrators.
“Sadly, Welsh Government has offered too little too late by way of funding and resources to help ease the ever-increasing burden on these doctors, and they are voting with their feet.

“What is urgently needed is dialogue between GPs and their patients, so that the public can get behind this important cause and exert the type of pressure that is needed to turn this sorry situation around.”

A spokesman for Betsi Cadwaladr University Health Board said the board was trying to find a solution that would see full time doctors take over at the practice.

He said: “We remain committed to providing a high quality service at Pen y Maes, which includes working to fill vacant posts at the practice. We are actively looking to fill vacant salaried GP positions at the practice, and will be interviewing for Advanced Nurse Practitioner posts next week.

“We continue to work hard to develop a plan for the long-term future and success of the practice, and apologise for any difficulties patients have had in booking appointments.”
A Welsh Government spokesman said: “We expect all Health Boards to provide primary care services which meet the needs of their populations. Investment in general medical service has increased by approximately £27m as a result of the agreed changes to the GP contract for 2017/18. This provides a strong platform for GPs to continue to provide high quality, sustainable health care across Wales.”

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Reasons behind the decline (Letters in The Times 14th October 2017)

Sir, You report that Jeremy Hunt is proposing to pay golden hellos to a limited number of younger doctors (“GPs offered £20,000 bonus to stay in neglected areas”, Oct 12), and that GPs who know patients personally are at risk of dying out (Oct 13).

I retired from my general practice in 2015 at 57 but carried on working as a locum until October last year because I did not feel ready to stop doing the job that I had previously enjoyed for most of my career.

Before my eventual retirement I had worked as a “family doctor” for 30 years in the same practice. I have never been afraid of hard work and many of my patients will remember the days when doctors were called out from home or would visit out of hours. But towards the end the pressure of the “day job” was starting to affect my health and was putting me at risk of “burn out”. I was also spending not much more than 50 per cent of my time in “real” patient contact.

To the many patients who would ask why I was retiring early, I would reply that the problems of general practice go back at least ten years, with governments of all political persuasions failing to listen to GPs. I would often say that the failure to listen to GPs went back as far as Tony Blair’s government, if not before that.

Although the government is beginning to make some belated proposals to improve GP recruitment I can also only guess how many GPs of my age and experience have been lost to the profession because of the inaction of successive governments.
Dr A G Bennett

Leek, Staffs

Sir, For a brief moment after the GP contract of 2004 was implemented GPs felt valued, but then the attacks began: an onslaught of criticism, started by Labour and continued by the Conservatives. It felt like a strategy: an intention to demoralise GPs. If so it worked, as general practice is now in crisis, with problems with recruitment and retention. And yet the health secretary states that GPs are the heart and soul of the NHS — if general practice fails, the NHS fails. What on earth was the GP bashing of the past 13 years all about?
Dr Bruce Halliday

Dumfries

GP practices close in record numbers – Wrexham patients protest about GP staffing levels. This is only the beginning….

Just cry at the bribery, and the Death of the Goose that used to lay the golden eggs that used to make the Health Service(s) so efficient, and the envy of the world.

How to kill the goose and create a shortage of 10,000 GPs – Patients kept waiting as new doctors shun GP jobs

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Hands up – who want’s to be a GP today? Recruitment is at an all time low despite rejecting 9 out of 11 applicants for the last few decades..

 

An infected UK health service – its beyond self remedy now, and needs radical surgery for the septicaemic contagion to be removed.

Never mind the news that antibiotics will be ineffective in a few year’s time. We have an infected UK health service – its beyond self remedy now, and needs radical surgery for the septicaemic contagion to be removed. Politicians continue to duck and weave, and none of them will face up to the measures needed. We are the only country in the world to pretend that we can have Everything for everyone for ever….

BBC News 13th October 2017: Antibiotics ‘may be lost’ through overuse, says chief medical officer

England’s chief medical officer is urging global leaders to tackle the growing threat of antibiotic resistance.

Medical experts say these drugs are being used too much, and that 25,000 people die across Europe each year because of drug-resistant infections.

Professor Dame Sally Davies says she is “really worried” that without effective antibiotics, common medical procedures such as caesarean sections and cancer treatments could become too risky.

The Nuffield Trust has published a new report on “Collaboration in General Practice”, which shows that not much is moving forward. GPs are set up as independent practitioners, who compete for patients. There is little incentive to collaborate, although as numbers fall the temptation to become salaried will be greater.

Thomas Mackie reports in The Express 30th September 2017: NHS failed to adapt to population growth and RADICAL action needed, hospital chief warns – THE NHS is not fit for the 21st century and has failed to adapt to population growth in the UK, the new chief inspector of hospitals has warned.

There are so few doctors and so few of those in training come from or aspire to work in rural and poor areas that the Express reports the bribes as “Doctors get £20k to go where needed”. This is to try to stave off the civil unrest which NHSreality has predicted for some time now.

The New Statesman reported 11th August 2017: It’s official – there’s a £200m hole in the Brexit bus NHS promise – The UK contribution to the EU budget was £156m a week in 2016-17 so the money is not there and the sums don’t add up.

Admitted in the Independent: 

Philip Hammond admits Brexit ‘no deal’ will mean less money for NHS and social care – Warning comes one day after the head of the NHS said cuts will be necessary without a bailout in next month’s Budget

and this is supported by Prof Max Exworthy of Birmingham University: The scale of re-couped EU membership costs is relatively marginal in the overall NHS finances.”

On 21st September and reported in the Guardian: Almost 10,000 EU health workers have quit NHS since Brexit vote – Staff losses will intensify recruitment problems at health service, which now has 40,000 vacant nursing posts

There are more and more trusts/hospitals in trouble.

Dudley.

Norfolk and Suffolk Mental Health Trust repeats the mistakes of the past.

Tayside may qualify as the first “civil unrest”…. as the citizens protest. The Evening Express: NHS Tayside faces ‘extremely challenging position’ of £50m funding gap

and Waiting times for NHS treatment are rising, figures reveal

Treatments are approved rather too late to help, and of course some such as  A A Gill will always be caught in the funding trap.

Where exactly is the State Safety Net? What state is it in? Will you fall through a hole when it’s your turn to need it?

 

Why won’t anyone in power talk about rationing? “We need to talk about NHS rationing”…

The downside of honesty must be greater than the upside – what an indictment of our media led society. Why are our leaders and administrators, trust chairmen and CEOs so afraid to speak out?

In Pulse 10th October 2017 David Turner opines: We need to talk about NHS rationing

A woman requesting breast reduction.

A child with severe behavioural problems in need of psychological assessment

A seventy year old brought to tears daily with knee pain, waiting for physiotherapy.

A new cancer drug costing thousands per month that has just received NICE approval.

What have these patients got in common? They all have a legitimate claim on the NHS pot of money for funding.

The recent announcement that NICE has approved nivolumab for treating patients with certain types of advanced lung cancer is fantastic news for those patients and will add valuable months to their lives.

There is, though, a rather large pachyderm in the room, which sooner or later needs to be faced. I’m afraid all of us – doctors, patients, managers and politicians – seem reluctant to address the rather obvious reality that NHS coffers are not infinite. Funds for healthcare are always going to be finite and even with the best political will in the world (and we certainly don’t have that at the moment) we cannot pay for everything.

Funding an expensive cancer treatment to give someone extra time on earth will impact on other aspects of healthcare. Increase funding to one area and others will suffer with reduced services and longer waiting lists.

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Do we say only disorders that can be fatal go to the front of the queue?

Many will say we should prioritise the most serious illnesses which can kill quickly such as heart disease or cancer. Nobody dies from osteoarthritis, but thousands suffers tremendous pain every day while waiting joint replacement surgery. It’s also not unheard of for people with mental illness to kill themselves while waiting to see a psychiatrist.

Name virtually any condition or disease and there will be individual sufferers and support groups making their case as to why more taxpayers’ money should be spent researching into or treating their disorder.

The reality is everyone’s health matters to them more than anything else and few people will be altruistic enough to say public money should be spent treating others before themselves and their loved ones.

I don’t claim to have the answers, but unless we start to talk more openly about the very real issue of rationing in the NHS we are just postponing some very serious questions for the future and they are not going to get any easier to answer.

Dr David Turner is a GP in west London

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Worried there may be an epidemic – of deaths, many alone at home… A precarious health service..

Niall Dickson opines in the Times 9th October 2017: This will be one of the NHS’s toughest winters and flu is not the only epidemic professionals fear. Mental health (Elderly, middle aged and teenagers), Diabetes from Obesity, staff bullying, staff attacks, drug addiction  and almost any other service you like to name.. The future of the whole NHS is precarious..

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It is becoming hard to overstate the perilous state of the health and care system in England. We have just polled our members — 92 per cent of healthcare leaders are “concerned” about their ability to cope this winter and 62 per cent of those are “extremely concerned”.
Last year the NHS managed well in difficult circumstances. Yet the impact on patients was evident. In early winter, waiting times in the big emergency departments rose sharply, with nearly one in five patients waiting longer than the four hours that is supposed to be the maximum. And there were ten hospitals in which less than 70 per cent of patients were seen within four hours.
This year there is an even greater sense of foreboding. There is much activity in central NHS bodies and an understanding of the political sensitivity of this issue — in part this is because of the obvious damage and distress that such delays cause patients and their families, but it is also because emergency departments are seen as a litmus test for the rest of the system. If the health service cannot cope at its front door, what lies behind it will also be struggling.
The causes are well known — we have a rising population. We have not invested enough in the services in the community that take pressure off hospitals, and we have a problem recruiting skilled staff. Emergency admissions are continuing to rise — in the first quarter of this year there was a 25.9 per cent jump in responses to life-threatening ambulance calls — so the ambulance service too is under increasing strain.

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The current levels of concern are heightened by fears that we may not escape a flu epidemic this year. Simon Stevens, CEO of NHS England, has pointed out that hospitals in Australia and New Zealand have been hit by the worst flu season in years; there is a good chance the same H3 strain is heading our way. A lot of work is underway not just to improve the flow of patients through hospitals but to relieve pressures elsewhere in the system. At the heart of all this will be effective planning and good co-operation across the entire health and social care system, but there is only so much that can be done.

A cash injection at this stage is unlikely to solve the winter pressures, but the chancellor must revisit the pencilled-in figures for 2018-19 and 2019-20, which if left as they are would guarantee more crises ahead and further delays to the reforms that are needed. For the longer term, the budget in November will be an opportunity for the government to underline its support for the NHS and to make sure it is deternot preside over a deteriorating service.

Niall Dickson CBE is chief executive of the NHS Confederation, a membership body for NHS health and social care organisations

Kat Lay reports: NHS straining at the seams as our bad habits add to pressure and Cash boost can’t save NHS from another winter crisis and Mental health staff attacked ‘on daily basis’

Chris Smyth: NHS is given six weeks to empty beds in flu alert

and Financially the lunatics running the asylum have run out of ideas in reigning in the cost of locums. Experience is very valuable in medicine and the most experienced radiologists, anaesthetists ans surgeons command high prices in their market, one created by politicians.

A perverse incentive epidemic, especially in mental health – both for GP’s pay/workload in UK and increased organ donors in the US, or dying, means that the systems are likely to get worse ..

An epidemic of nationwide bullying. In most dictatorships this precedes dissolution or breakdown….

Rosemary Bennett 10th October : Half of expelled pupils are mentally ill

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BBC News reports “peanuts” spending: Scottish government announces mental health funding boost

Nick Triggle for BBC News: NHS future precarious, says regulator

Performance related pay schemes, such as QOF, are not suitable for professionals.

Management courses have taught for a long time now that Performance Related Pay (PRP) has a short half life. The box ticking production line style of management is not for professionals. The QOF (Quality Outcomes Framework) is another form of PRP and has been in existence for far too long. Elderly multi-pathology and terminal care patients are the future of primary care, and their care will mostly have to be at home. Hospital at home projects are the future, and they will need staffing…… Lets hope we can train them up from our own population, because we have alienated the immigrant labour force. NHSreality agrees that there may be a sudden surge in deaths from epidemics such as flu, and most of these will have to be at home. Commissioning groups need to abolish QOF, remove the perverse incentive to ration those services that pay less, and trust the overstretched GPs to ration their care appropriately.

Kat Lay reports 10th October in The Times: Cash incentives for GPs do not make care better

A financial incentive programme for GPs may not improve the quality of care, according to researchers.
The quality and outcomes framework, introduced as part of the 2004 GP contract, means that up to a quarter of a surgery’s income is linked to targets on areas such as heart disease, diabetes and smoking.
Researchers from University College London and Imperial College London reviewed a series of studies evaluating the worth of such financial incentives.
They found that although a number reported initial improvements in the treatment of a range of chronic diseases such as hypertension, diabetes and asthma, these were often not sustained. Any positive effects were not consistent across ethnic, gender and age groups.
There was also a suggestion that patients whose conditions were outside the framework “experienced higher mortality and poorer quality of care”.

The study, published in the British Journal of General Practice (BJGP) will add weight to calls to scrap the scheme. NHS England has said it supports such a move in principle but failed to make any changes in the latest round of GP contract negotiations. A year ago, Simon Stevens, the chief executive of NHS England, said: “For the most part it has descended into too much of a box-ticking exercise.”

Last month a review commissioned by NHS England concluded that the framework did not improve care and should be replaced, but cautioned that removing it could have a severe impact on GP practice incomes and patient care. The study’s authors warned that any new incentives should be looked at carefully. “Despite uncertainly about their effectiveness, financial incentives receive widespread political attention and are increasingly being implemented,” they said.

A spokesman for the British Medical Association said that the framework had “helped deliver substantial improvements to patients across the UK” and had raised detection rates.

•A survey in the BJGP found GPs were concerned about the introduction to the NHS of physician associates, graduates without traditional medical training. Patients, however, had fewer fears.

 

Tears, tantrums and no pay – my life on a zero-hours contract in the NHS

You get what you pay for — which, for most NHS users, is nothing

NHSreality response to the RCGP Questionnaire into the future of Welsh health and social care

A fearful anonymous consultant tells it as it is… “the NHS is in crisis”.

Fighting for the NHS’s moral life: There are 4 Chernobyl’s waiting for meltdown..

Getting to see a Health Service physio – like getting to see a health service dentist

 

A stillbirth is not a person: so no coroners inquest. But the rates differ greatly around the country… Lets stop the blame culture winning..

A sad and disturbing case illustrates a greater problem. The rates for Stillbirth in Wates are 20% higher than in England. Has this always been the case? On June 15th this year I wrote to the Chief Medical Officer of Hywel Dda University Trust asking for information on the rates of Maternal Death, Neonatal Mortality and Infant Death for the Trust, compared to the all Wales and to the all UK figures. I received the acknowledgement reply and was informed I would get a proper reply in 7 weeks. It is now some 14 weeks later and I have not had a reply. The case in the news involves intelligent and well informed professionals, who wish to remain part of a team and work  within the health service. They are not trying to “gain”, but wish to change a culture so that learning occurs, and repetitive mistakes do not happen. If we wish to avoid the blame culture we need open and honest debate. No fault compensation would help greatly… Meanwhile I am writing again and including Stillbirths in

Lucy Bannerman reports in the Times 7th October 2017: Parents call for NHS stillbirths to be investigated

Two health professionals whose daughter died during labour after a series of hospital failures have called for coroners to be given power to investigate stillbirths.

Sarah Hawkins and her husband Jack said that it was “absolutely ridiculous” that baby deaths in England and Wales only merited the independent scrutiny of a coroner’s court if the child was alive when born.

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Their daughter, Harriet, died in April last year, at 37 weeks, after errors by Nottingham University Hospitals NHS Trust, including repeatedly denying Mrs Hawkins admission to hospital and failing to declare an obstetric emergency.

Mrs Hawkins was in labour for five days and after being told the baby was dead had to wait nine hours before Harriet was delivered.

Both worked for the trust, she as a senior physiotherapist and he as a consultant, but when they asked for an investigation they said they “were dismissed as mad, grieving parents”.

Mrs Hawkins, 34, said: “It just felt they were saying, ‘This is very sad, these things happen, now go away and grieve’. But we have both worked in the NHS all our careers. We wanted to tell them what they needed to know, to make sure it wouldn’t happen again.”
The couple were told there would be no inquest because the law states that a stillborn child or foetus is not a “deceased person”. “As a mum, to be told that your daughter isn’t defined as a person, because she wasn’t born alive is absolutely ridiculous. She had been kicking around, and had her foot under my ribs for months,” Mrs Hawkins said.
The couple said they were told by the trust that Harriet’s death was caused by an infection. It was only after challenging that and pushing for an external review that the death was “upgraded” to a serious untoward incident (SUI).

“It has been battle after battle after battle,” said Mrs Hawkins. “We don’t want sorrys. We want answers.” Mr Hawkins, 48, said: “I don’t think they really had a clue that the death of a baby in labour was a major incident. Their attitude was very laissez faire.”

Peter Homa, chief executive of the trust, has apologised but denied a cover-up. “I reiterate my condolences to Jack and Sarah and acknowledge the unimaginable distress and sadness caused by Harriet’s death,” he said.

“I apologise unreservedly that their pain has been worsened knowing that, had the shortcomings in care late in Sarah’s pregnancy not been experienced, Harriet might be alive today.”

The couple believe their daughter might have lived had inquests been held into previous stillbirths at the trust. They want the law to be brought in line with Northern Ireland where coroners can investigate stillbirths.

Mrs Hawkins vowed to keep campaigning. “We want to get justice for Harriet but also for all the other parents before us, and after us,” she said.

ITV News 5th October: ‘Now we want justice for our daughter’: Hospital says failings in …

ITV News yesterday: Hospital trust apologises for failings after stillbirth of employees …

Hospital apologises to parents of stillborn baby for ‘unimaginable … Nottingham Post

 

Sands – Stillbirth and neonatal death charity