Despite pressure from campaigners, NHS England has indicated that it will not publish results of a national audit prompted by the death of a baby girl.
The organisation has been exploring the quality of investigations that were carried out after the tragic incident took place.
But the commissioning body has indicated that although it accepted the recommendations of an independent review, it will not make public the methodology or findings of a national audit suggested by it.
The process had been instigated by the untimely demise of baby Kate Stanton-Davies.
Kate tragically died at a midwifery unit run by the Shrewsbury and Telford Hospitals Trust in March 2009.
It is accepted that there were numerous failures made at the unit at the time of Kate’s death.
The parents of the child have reacted angrily, not unreasonably pointing out that they expected to see a process that could be described as transparent.
Yet NHS England has described the ongoing reaction to the investigation as an internal matter.
NHS England is the existing supervising authority for midwives practising in England.
As part of this responsibility, the organisation commissioned expert Debbie Graham to review events surrounding Kate’s death.
This followed a jury inquest and an investigation by the Parliamentary Health Service Ombudsman in 2013 which both concluded that the death was avoidable.
Both processes also concluded that there had been huge failures in the care throughout the time that Kate stayed in the hospital.
Graham went on to heavily criticise the local supervisor, suggesting that the quality of investigation carried out have been entirely unfit, particularly in terms of containing multiple inaccuracies.
The report had stated at the time that NHS England should carry out an audit in order to “seek assurance that the weaknesses in the investigatory process identified in this review are no longer inherent in the current process.”
Yet it seems now that the results of this process will never be made public. It is those understandable that parents of the infant are extremely disappointed by the process.
According to investigations, Kate was born “hypothermic, pale, floppy and grunting” at Ludlow midwifery led unit in Shropshire, in March 2009.
Her mother had been incorrectly classified as being low-risk.
That decision will be viewed as controversial, and indeed there will be question Marks regarding precisely why it has not been published.
It seems that these questions will go unanswered.