The inquiry revealed that the hospital trust prioritized reputational concerns over actual safety risks, indicating a critical failure in recognizing the seriousness of neonatal mortality rates.
Counsel Nicholas de la Poer highlighted that the mortality rate risk was only acknowledged in July 2016, long after it became apparent, demonstrating negligence in addressing patient safety.
During the review period from June 2015 to June 2016, a striking fact emerged that discussions about the rising mortality rates at the neonatal unit occurred only once.
The focus on reputation over safety within the hospital governance framework allowed critical issues regarding patient care to be overlooked, contributing to tragic outcomes.
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