Ex Nhs consultant doctor. Father of two but only one alive. Successfully exposing recurring issues at Nottingham University Hospitals. Happy to talk with anyone
I’m sat outside, the sky is clear and the stars are out. I had a lovely day today with child 2. Child 1, Harriet, is up with the stars and my heart aches
#BLAW2022
#saytheirnames
My baby girl Harriet finally had her funeral 5 years ago today. She was nearly two. She spent all that time in a freezer. Eventually people (names names) admitted liability and negligence and we carried her to her final resting. I am so sad ❤️
My first daughter Harriet was born 6 years ago. I love being her father, I’m heartbroken that she’s not here. That she is dead. That she should be alive and that all the people who needed to know knew that her death was possible yet didn’t act. Harriet. My beautiful 😍 ❤️😊
I’d like to say that we do not agree with the cqc right to reply that they only became aware of Harriet’s case 4.5 years after her death. We have their emails to prove this.
Harriet was warm when I first held her. The last time she was freezer cold. God I loved holding her. She was in NUH freezer for near 2 years until they admitted liability. In that time we had 2 messages, one from board, to see if we could move her to a ‘more appropriate place’
In 2016, when we realised we were being actively obstructed in our avoidably dead daughter’s investigation, we wrote to the board and said ‘you’re behaving like mid staffs, you’re conducting a cover-up and your governance is so bad you wouldn’t know if Beverly Alit was here
A question. A senior clinician tells you that they know that their colleagues have lied in coroner’s court. What should they do? What should you do? Please RT cos it’s a good question.
@TaskerAnn
please RT as you have a different group of followers than me
Why? Why is this allowed? Ugh. If I’d known my family was at risk of this quackery I’d have been able to behave differently and help keep my daughter alive
@nmcnews
@MidwivesRCM
@RCObsGyn
@catherineroyuk
@croydonhealth
Please don’t
@CroydenHeath
. Advertise for safe midwives. If they can work and do everything safely then and only then can they offer to make the room smell different with smells. And then stop that smell focus as soon as there is a change in mum or baby.
@DebDavis100
@Nishaobgyn
My dead baby says we’d have liked to know how things go wrong. We could have been part of the safety of our child. I’m a bit shocked this is a professorial view. I’m going to remove all the ‘how to get out of this plane’ info next flight..mustn’t scare people
@MartynPitman
It’s not ‘trusts’ though. These are people with names. The medical director. The chief executive. The comms director. It isn’t the window frames making it happen. It’s the people. And it’s a choice
@catherineroyuk
@NHSNotts
This triggers me. The midwives, in the midst of an obstetric emergency, discussed which of these smells to use. I feel sick. It’s a horrible memory. My daughter needed urgent help. There’s a sketch, Mitchell and Webb homeopathy emergency. Have a look. It’s funny…NUH 🥹
@ShaunLintern
@nottmhospitals
Until recently it was us, Harriet’s parents, who were in the wrong. Nuh ‘reiterated their condolences’ (like they’d witnessed our cat run over rather than being involved in Harriet’s death by their gross negligence). Now, at last, people are starting to see we are honest
This is my perfect eldest daughter, she should be here celebrating Mother’s Day with us. Thinking of all those Mum’s and families today who don’t have their much wanted and loved child to hold
#MothersDay
#grief
#babyloss
Dr Keith Girling, Medical Director at Nottingham University Hospitals Trust, added: “We are sorry to those people where there has been any form of incident during their care.” Like a dead baby or dead mum. ‘Any incident’??
Does anyone think we need to watch for the NHS trying to set the terms of reference for our new review into Nottingham maternity services before families get a chance to get involved?
.
@DOckendenLtd
has been appointed as chair of the independent review into
@nottmhospitals
maternity services.
I thank her for taking on this vital role. We will work with the NHS to ensure no families suffer like this again and I look forward to seeing her recommendations.
@EmilyJBarley
@NormalBirthConf
I would love to be chasing Harriet around, nearly 7 years old, but she died due to negligence. Aromatherapy instead of proven safe care is just one example. It’s awful. Who are these people that won’t listen or follow NICE etc etc
@EmilyJBarley
She also laid into obstetricians. This is the exact issue we think is appalling. How can one profession deride another when they have exactly the same goal-the safe delivery of a healthy baby.
It’s awful isn’t it. Not a single ‘body’ has made it easy. And that’s as a hospital consultant who has some idea of the rules and the system. How shall we change it 😊?
‘Tragically, around 100 of the 700,000 babies born in the UK each year die because something happens during labour and birth that is not anticipated or well managed.’ Is this RCOG statement true?
@meynell_kate
is it true that you have found the time to meet with the CEO of the defendant organisation yet not to meet with victims? Is it normal practice when there are alleged crimes to meet the defendants first? And to offer them assurances?
@LilianGreenwood
This is a positive start. Just a thought on language. My Harriet isn’t ‘lost’. She is dead from known and avoidable failings. Can I suggest senior NHS (and anyone really) use the real words. Dead. She died. Avoidable.
@CNOEngland
Chief nurse
@CNOEngland
has apologised for "terrible failings suffered by many families" in maternity services adding she was "deeply sorry for the loss and the heartbreak". She said the Shrewsbury report was a "call to action" to improve care across England.
#maternitysafety
@Sajhawkins1
It does. Our daughter. The hospital admitted their negligence in her death, though not for 18 or more months when it was obvious at the moment they told us she was dead. Now a massive investigation is underway with thousands of potential victims. Harriet. I want you here ♥️🥰♥️
@Sajhawkins1
@sajidjavid
@DOckendenLtd
I held her. It was the most confusing feeling ever. She was perfect and human. I tried to force my heart into hers, beat heart, please beat 💔
@sajidjavid
@NHSEngland
@aidanfowler1000
please look at my beautiful eldest daughter. A full term heathy baby, left to die during a 6 day labour. Then left for 9 hrs trying to deliver her dead because of communication errors. Tell me what you would do now if this was your child ?
We blew the whistle to 2 consecutive medical directors. We expected the 2nd to act. He did. He ended my contract and I received my P45 between Christmas and New Year. ‘Merry Christmas and a Happy Bew Year! No salary for you!’
@peter__duffy
Thank you. Cruelty on cruelty. We suggest knowingly and not accidental. NUH have never acknowledged the damage they did to us by their behaviour. It’s why when the ‘reiterate their condolences for Harriet’s death’ we recoil. Still they do not care. That you do is truly lovely 😊
@EmilyJBarley
I’m one of ‘these people’. I don’t like that, either that my child is dead despite the use of lavender oil or that I am called ‘these people’. The lavender oil is true btw. Maybe it was ylang ylang. Anyway she died from negligence
We know there are massive problems at Nottingham maternity. We have a long history of the right people being ignored and the wrong people being heard. Saville. Rotherham. The church.
@sajidjavid
I’m sure the local NHS will be lobbying you. Do they have reason to not want scrutiny
Possible reasons why
@NHSEngland
feel Donna Ockenden is not needed at Nottingham’She is too expensive’. The care for one severely brain damaged child is £10’s millions. DO team might cost, what, £5-7million. GIRFT would be cheaper
@sajidjavid
Ummm. I don’t mean to be negative but this is part of the problem. Talk to us. You’ve got the contact details of so many parents. Yet communicate with us via the press. You’ve already lost a lot of us. And the words…what do they mean??
Instead it said: “it is absolutely right that they have their experiences of poor care responded to and learned from. The next steps of the review including engagement with families will be set out shortly.”
Can National Freedom To Speak Up Guardian really claim with straight face that it's definitely safe for NHS staff to
#SpeakUp
to
#FreedomToSpeakUp
Guardians who have serious conflicts of interest?
Does she even know how many conflicts of interest exist?
You know what the attitudes are behind closed doors. This. This is a pattern as well, with the recent public announcement by the board that we need to draw a line under this maternity scandal and move forwards
Reasons why
@NHSEngland
may be avoiding sending Ockenden to Notts ‘NUH will feel it unfair’. NHS is for safe care, not board reputation. Wouldn’t we expect NUH to be demanding Ockenden as they want to provide the best and safest care to the city and county
@sajidjavid
"We knew as soon as they told us Harriet was dead, that something was wrong"
Families demand completely independent inquiry into failing maternity services at Nottingham University Hospitals NHS Trust
@mancunianmedic
David they inject saline sun cut for pain relief. RCT with water as a placebo. It’s bizarre. Our MWs had a discussion about which of 2 oils to use without monitoring our dying daughter. It’s utter madness. It’s not even 1970s care. The police are investigating
@MartynPitman
We want to understand too. Our subject access request reveals some me truly awful attitudes and behaviours. We say incompatible with professional registration. There should be hundreds of WB letters to the board from obs consultants but we suspect there are not
There was so much to learn from Harriet’s death. Get this enacted now. They did the job of caring for us sooooo badly Harriet was died just before birth. Denied everything the coroner affords to families. Law! Now!
Coroner jurisdiction for stillbirth: Patient Safety Watch newsletter
@jeremyhunt
highlights the unacceptable 3 year delay in publishing the feedback from the Consultation & delay in implementing the change in law. It is imperative that Coroners have this jurisdiction
@JamesTitcombe
Yup. It felt a bit like projection. Anyhow. Back to trying to prevent other people having to experience the avoidable death of their completely normal baby by negligence and trying to support others like us. Following ☺️
@BabyLossLawyer
Well we won’t stop. Of course. We’re so grateful for the huge support we get. We are very concerned about some behaviour by names in Nottingham and nhse but we will surely expose it. Tomorrow’s a new day and we are looking forwards to what appears to be new with NUH ceo/chair
@jesshedomanlees
@EmilyJBarley
@NagingtonUoM
I’m sorry to retweet this without asking but our voices need to be louder. This attitude (from far far too many drs and MWs) would have planes taking off with doors open. There are too many bereaved and terribly harmed to be minimised anymore 💔♥️
It’s called victim blaming. “You, you stop smoking! Meanwhile we will continue to fail to deliver safe care or to hold anyone to account for avoidable baby deaths.”
We are in no doubt there were other completely avoidable baby deaths in Nottingham because the information from Harriet’s stillbirth was able to be ignored
A life I never expected to live… being an unnecessarily bereaved mother to my eldest daughter 💔 however we also have so much to be thankful for. To everyone who believes us, supports us and continues to talk about Harriet, Thank you.
#ThankYouDay
#maternitysafety
I’m very saddened to see this. It’s difficult to see how an inquiry of this nature can be meaningful if the starting point isn’t a process of building trust through careful listening and sensitive engagement with the families affected.
Good stuff. That slide being up is serendipitous. Nottingham has areas of very high deprivation, and a large and diverse population. Here’s hoping our (at last) proper review of maternity safety will help those currently disadvantaged to have a voice 💔❤️
NUH familiar response to yet another baby death “Rare, complex and tragic”isolate, isolate and isolate the victims and minimise what actually happened.
Because it was more important to the individuals who could and should have been honest to mislead, gaslight, obstruct. Why? Well not everyone is good and would benefit from the no blame culture were told us the solution.
#Nottingham
It's taken 6 years of lies, denial, excuses, to reach the point where they MIGHT find out why, instead of a 6 year old daughter, these parents have only memories & photographs. WHY??
@nottmhospitals
How about the failures since then, both in the treatment of the parents and the failures to listen and learn that must surely have led to more avoidable deaths and harm. Notice Rupert says ‘The mistakes we made AT THE TIME’. Yet they are still inadequate. Notice
@NHSEngland
@GibbleJo
@JamesTitcombe
@UCLan
We, the harmed, are not the problem. The cult is a problem. Stop behaving like a cult. Start listening to the hard stuff.
@ShaunLintern
@DanielleJ1988
@DOckendenLtd
@nottmhospitals
We recognise this too Danielle. There is great care at NUH. There are great British Airways flights. But when the Kegeorth air crash happened I don’t think BA ignored the dead people and said ‘look at our other planes!’ We didn’t want or need to battle. NUH made it so we had to
@JC1Dubb
Reputation. Manage the reputation. Of the organisation and for your leadership CV maybe? The pain hurt and damage done is just not theirs to live with
Another possible reason to not give what we need. If
@NHSEngland
agree with Notts families that Ockenden is the right team then they will not be in control, what next then? Well, ‘patients’ should be at the ❤️ of the NHS. Please do it right for us
@sajidjavid
@CNOEngland
Sent to NUH in early May for factual accuracy check. Not sent to families for any checks because ?no facts from families? ?no facts worth believing? What reason exactly? If the review team and boses are confused why they’ve gone, it’s this
In early May
@nottmhospitals
was sent the interim report by the review team into maternity deaths to check for accuracies. It’s now May 26 & the families affected by those deaths& harms have still not seen it. Doesn’t seem a v independent process.
If you’re watching this, please feel everything you want for the poor families of Shropshire. And bear in mind this is Nottingham too. I hope families of SAFT don’t mind me doing this ❤️
An injustice anywhere is a threat to justice everywhere. Quite like it. Sweeping, but if there is no accountability how can we get better people in powerful jobs
A really important message ⬇️ - bullying can take many forms - sometimes direct & obvious - sometimes more subtle & hidden. We all have a duty to look out for it & to speak out when we see it.
Conversation between harmed families at Nottingham…if Ockenden does come to Nottingham she and her team will not need to spend months building trust. Months saved. Money saved. Mental health saved. Less harm
@NHSEngland
@sajidjavid
As a doctor I have been be
@used
and horrified by
@gmcuk
approach. Drs lied, drs behaved at the level that would have failed medical school exams we say, yet nothing. Another failed organisation?
What about working with unnecessarily bereaved parents
@gmcuk
? An investigation into our clinicians was completed without our knowledge/ input and based on incorrect info. When we raised concerns about this another investigation was completed without our input again!
#failed
@Kimberleyerrin2
That’s just awful. Did they use the word phrase ‘we can’t reconcile these conflicting accounts (between you and the maternity team) and in essence ‘side’ with the hospital? They do it to do so many causing untold grief and harm
Neither of us smoke. Neither overweight. Stuck up for ourselves. Accept risk…dead baby and massive attempt to cover up. So. Nope. It’s complex. There is no easy solution or even any solution, just a forensic fascination by care teams to improve.
@SarahFairley7
Thank you ☺️. The outstanding question is ‘why?’ That requires honesty from people who absolutely can be honest. Maybe they will be soon
@mjrsimmonds
@ShaunLintern
@ICMdoc
In fact Mark. Where have you been. I hear you’re deputy medical director now. There will be 10s probably 100s of cases of avoidable harm including deaths at NUH. When there was the horrible stabbing here you commented on that. But nothing for us, harmed by your Hosp. Why?
@catherineroyuk
What’s he going to do about it? We will be clear that he now needs to support the nhs by supporting families give the info to a court to hold his predecessor’s to account
I think we need to consider Each Baby Counts data with huge scepticism. It is self reported with considerable data quality issues. NUH self reported. East Kent. Morecambe bay. SAFT. Still 100 seems incredibly low
@jackhawkski
I think the number is higher. This is from the 2019 Each Baby Counts progress report. 130 intrapartum stillbirths and 150 neonatal deaths within 7 days of birth. All term babies (> or = 37w gestation).
@RMatthewsPsyEdu
@ElaineReplogle
@robllewelyn
The RCOG admitted that it was ‘usual’ for colleagues to receive consultant delivered care whatever the risk. So presumably they know it’s unsafe and come in when off duty to deliver ‘more important’ babies. While leaving the poor safety to others
@sajidjavid
Donna Ockenden’s report says these multiple reviews don’t achieve what is needed. Don’t put us through another review (there have been so many here already). Get into this. It’s easy. Say yes and let’s get it better
Yup. I wasn’t expecting it and the instant emotions had me crying. The look on Lottie’s face was pure joy 🥰. So you know, we talk about Harriet with Lottie, openly and appropriately for her current understanding.
We were at the park last week with our 2 year old.
Lottie came running up to us with her new friend who was called Harriet.
“Mummyyy, Daddyyy I’ve found Harriet and she’s not dead” 💔.
Imagine this for the rest of your lives.
Imagine this stress
@NottmMaternity
@autinveniamviam
@RMatthewsPsyEdu
What is interesting is just how many senior medical health professionals get their consultant Obs colleagues delivering their babies. Just to be on the safe side, or, in another view, we know what we offer ‘you lot’ is riskier
@EmilyJBarley
NUH board tried (and succeeded) for years and years to satisfy themselves and nhse that their benchmark against other trusts was ok. All the while harm and death. 1700 over 10 years is 3.2 a week of serious harm and death.
@mancunianmedic
Also thanks for reading about maternity. Means a lot. It’s not staffing. It’s bad care wrapped up in Al sorts of ideology. Imagine you have a collapse. 2 teams. One does hx+ex+bloods+ecg. One doesn’t and says it’s normal and you need to accept it. That’s maternity.
A major concern is the difference between this internal message and the messages to the press and externally. There they ‘welcome’ and will ‘fully engage’ or similar phrases. Why different? Something is wrong for this to happen
A memo from
@nottmhospitals
after
@DOckendenLtd
visit to families. It must be stressful to have your service under a spotlight but nothing compared with the despair of those families who’ve suffered loss and harm and had no answers.