Improvements plan for Walsall Manor after two damning probes

Members of Walsall Healthcare NHS Trust met for the first time since independent reviews found a baby who was shaken to death may still have been alive if he had been referred to social services and how almost 90 foetal remains were kept for up to four years.

In both cases it was said actions have been taken and more are being undertaken to avoid a repeat at the Manor.

The trust board yesterday agreed a number of recommendations following the review into the death of 16-month-old Kyle Keen who suffered a bleed on the brain.

He had been admitted a few days previously where bruises were noted but no follow-up action was taken and he was discharged.

The toddler, from Walsall, was then admitted again and was transferred to a specialist unit in Stoke with a brain injury and died a day later in 2006. Kyle had been shaken by his stepfather Tyrone Matthews, then aged 25, who was sentenced to six-and- a-half years in prison for manslaughter.

The report found there was a 'significant probability' he would not have died if action had been taken to intervene at the time.

The board made a public apology to Kyle's father Rob Keen, who attended the meeting, and agreed to take improvement actions and follow recommendations from the review.

This includes improving the quality of record keeping, a campaign to encourage staff to highlight any concerns and how it works alongside partner organisations.

Chief executive Richard Kirby said the main things the review highlighted was Kyle should have been referred to social services, investigations at the time should have been better, and Mr Keen should have been kept informed.

On the issue of if staff had a different opinion Mr Kirby said the default should be a referral, which is now part of the policy.

Speaking afterwards Dr David Drew who worked at the Manor and claims he was a whistle blower in the case of the toddler, helping advise Mr Keen to get answers, said the question of why it has taken eight years remains unanswered.

Mr Keen, aged 32, said: "It is everything I had already heard, at least they are taking the steps to put forward what they said they are going to do. But I am still not going to get the answers I wanted."

The board was told actions were also being taken after a report published this week showed weak leadership, missing paperwork and historical practices led to the remains of nearly 90 unborn babies kept for up to four years.

The scandal at Walsall Manor Hospital came to light this year when a total of 86 foetal remains were uncovered.

Areas highlighted as in need of addressing include senior members of staff taking greater responsibility and accountability, creating proper procedures, and establishing a comprehensive bereavement service. Measures being taken to avoid a repeat include monthly audits in the mortuary.

Jayne Tunstall, chief operating officer said: "Actions have already commenced. The trust has taken the situation very seriously."