Failures at Walsall Manor led to baby remains scandal
Weak leadership, missing paperwork and historical practices at Walsall Manor Hospital led to the remains of nearly 90 unborn babies kept for up to four years, a critical report revealed today.
The scandal at Walsall Manor Hospital came to light this year when a total of 86 foetal remains were uncovered.
An independent investigation has exposed a string of startling failures that led to the remains of abortions and miscarriages never being released for cremation.
The review by Sandra Gray of Buckley-Gray Consultancy found:
- There was no trust-wide policy for dealing with the storage of foetal remains, just 'historical customs and practices.
- A history of clinicians in the obstetric and gynaecology service not filling out documents meant responsibility fell on a single pathologist over 12 years.
- There had been no mortuary manager since 2010 with no formal training given to staff picking up responsibilities.
- It became the norm for between 30 and 60 foetal remains to be held in the mortuary.
- There was no regular audits of policies and practices with weaknesses in the governance and management of risk concerning the backlog of foetal remains.
- And a lack of recognition and or appreciation of what constituted a serious incident.
The hospital board will discuss the findings on Wednesday, which highlights eight main areas that need addressing.
They include senior members of staff taking greater responsibility and accountability, creating proper procedures, and establishing a comprehensive bereavement service.
Walsall North MP David Winnick described the fiasco as 'distressing' while medical lawyer Mandy Luckman of Irwin Mitchell has revealed the firm has been approached by people affected by the scandal.
Mrs Gray said the number of remains were only discovered as the hospital tried to respond to a Freedom of Information Act request.
The review states: "There is evidence that the trust has implemented a strong governance framework, however, there was no complete oversight of the system or rigorous facilitation for the timely disposal of foetal remains.
"Moreover, the processes in place for the governance of quality although improving are not fully embedded within the organisation.
"Sustainability of the necessary changes will be crucial to maintain sound systems of control, effective improvements in risk management, assurance and continuous quality improvements of this service."
The trust said a full training plan was being put in place to ensure lessons were learned. A report to directors states: "The action plan now developed from the external review recommendations will be implemented at pace in order to ensure the risk of such an incident happening again is mitigated."
Two of the cases date back to 2010, a further two in 2011, a total of 30 in 2012 and then 52 up to December 2013.
Around 700 foetal remains are kept at Walsall Manor every year until the appropriate paperwork has been completed.
The hospital said it then 'appropriately disposes' of foetal remains through the crematorium in line with 'usual processes'.
Such remains are usually stored in the hospital's mortuary for between one and three months.
Then, in the vast majority of cases, they are sent to be cremated.
However, an error in getting documents signed off to allow this to happen led to the foetal remains in these cases being kept for up to four years.
In 73 cases they belonged to foetuses under 12 weeks with the remaining 13 being under 21 weeks.
The trust has since carried out 81 of the 86 cremations with three burials being organised.
The remaining two have separate arrangements agreed with families. At the time the scandal emerged, Richard Kirby, chief executive of the Walsall Healthcare NHS Trust board, told the Express & Star: "I would like to apologise to each and every patient who has been affected by this and would like to re-assure anyone who might be using our services now or in the future of our dedication in ensuring that this situation does not arise again.
"We are confident we have contacted everyone we need to in relation to this issue."
A dedicated hotline has also been set up for anyone with concerns.
The number to call if anyone does have any worries is 0345 835 7626.
- Scandal of the unborn babies kept for up to four years at Walsall Manor Hospital
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