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.

Homertons apparent failure to disclose a particular midwifes 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
CCGs 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 Kirkups
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 [1] of the Homerton
Trust board are wholly white.

Please disclose:

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.


Yours sincerely,

Dr Minh Alexander

[1] 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 Hacney South and Shoreditch
Shadow Secretary of State for Health
Health Committee
Public Administration and Constitutional Affairs Committee

 Public Accounts Committee

Sir Peter Bottomley MP
Rt Hon Sir Anthony Hooper
Sir Robert Francis QC
EHRC
Professor Sir Bill Kirkup
National Maternity Review