Here are the main points from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust:
– The inquiry, which examined cases involving 1,486 families mostly from 2000 to 2019, found “repeated errors in care” which led to injury to either mothers or their babies.
– Maternity expert Donna Ockenden, who led the review, said the trust “failed to investigate, failed to learn and failed to improve”.
– Some 201 babies could have – or would have – survived if the trust had provided better care.
– Most of the neonatal deaths occurred in the first seven days of life, with nearly a third of all incidents reviewed (27.9%) identified as having significant or major concerns in the maternity care which might or would have resulted in a different outcome.
– 498 cases of stillbirth were reviewed and graded, and one in four cases were found to have significant or major concerns in care which if managed appropriately might, or would have, resulted in a different outcome.
– There were 12 maternal deaths reviewed and in nine of the 12 cases (75%) the review teamidentified significant or major concerns in the care received.
– Ms Ockenden said staff were frightened to speak out about failings amid “a culture of undermining and bullying”.
– Staff also claimed they were advised by trust managers not to take part in a “staff voices” initiative set up to assist the investigation into what went wrong, according to Ms Ockenden.
– The review team identified 15 “immediate and essential actions which must be implemented by all trusts in England providing maternity services”.
– These include matters such as workforce funding, planning and sustainability, safe staffing, escalation and accountability, leadership, investigations of incidents and complaint handling, learning from the deaths of mothers, multidisciplinary training, complex antenatal care, pre-term, labour and birth at term, obstetric anaesthesia, post-natal care, bereavement care, neonatal care and supporting families.
– Ms Ockenden said it is absolutely clear that there is an urgent need for a robust and funded England-wide maternity workforce plan starting right now, without delay, and continuing over multiple years.
