Mothers and babies died or suffered major injuries due to “repeated failures” at an NHS trust, an independent inquiry into the UK’s biggest maternity scandal has found. Shrewsbury and Telford Hospital NHS Trust presided over catastrophic failings for 20 years – and did not learn from its own inadequate investigations – which led to babies being stillborn, dying shortly after birth or being left severely brain damaged.
Several mothers died after failings in care, while others were made to have natural births despite the fact they should have been offered a Caesarean. Some babies suffered skull fractures, broken bones or developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries.
The damning report, led by maternity expert Donna Ockenden, examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents. It is the largest-ever inquiry into a single service in the history of the health service and has wide-ranging implications for the maternity in the NHS.
The inquiry was ordered by Tory MP Jeremy Hunt in 2017 when he was health secretary. He said on Wednesday the numbers were “worse” than he could have imagined and he hoped the report would be “a wake up call”.
The inquiry identified “hundreds of cases” where the trust failed to undertake serious incident investigations, while deaths were not investigated appropriately. As well as major issues within the trust, the report pointed the finger at external bodies, which did not effectively monitor the care provided.
Where investigations did take place, they did not meet expected standards and failed to identify improvements, meaning lessons could not be learned and families experienced repeated serious incidents and harm. Ms Ockenden said: “Throughout our final report we have highlighted how failures in care were repeated from one incident to the next.
“For example, ineffective monitoring of foetal growth and a culture of reluctance to perform Caesarean sections resulted in many babies dying during birth or shortly after their birth. In many cases, mother and babies were left with life-long conditions as a result of their care and treatment.
“The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved. There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths.
“What is astounding is that for more than two decades these issues have not been challenged internally and the trust was not held to account by external bodies.
“This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding. Going forward, there can be no excuses.”
Ms Ockenden’s team of investigators found families were locked out of reviews when things went wrong and were often treated without compassion and kindness. The trust, which is currently ranked inadequate, was also found to have repeatedly failed to adequately monitor baby’s heart rates, with catastrophic results, alongside not using drugs properly in labour.
Leaders and midwives were found to pursue a strategy of keeping Caesarean section rates low, despite the fact this repeatedly had severe consequences. In an interim report published in December 2020, Ms Ockenden noted that for around 20 years the Caesarean section rate at the trust was consistently 8% to 12% below the England average, with this being held up locally and nationally as a good thing.
Her review team formed the clear impression there was a “culture” within the trust to keep Caesarean section rates low – perceived as the “essence” of good maternity care in the unit. David Redford, then a clinical director of women’s services in Shropshire, is on record telling several MPs in 2003 (some of whom themselves praised low Caesarean rates) that “the culture of our organisation is that we have low intervention rates and, once that is known, we attract both midwives and obstetricians who like to practise in that way.”
Richard Stanton and Rhiannon Davies, who have campaigned for years over the poor care, lost their daughter Kate hours after her birth in March 2009. The trust noted the death but described it as a “no harm” event, although an inquest jury later ruled Kate’s death could have been avoided. The trust still insisted its care had been in line with national guidelines.
Another couple who have led the campaign for safer care are Kayleigh and Colin Griffiths, whose daughter Pippa died in 2016 from a Group B Strep infection. A year later, a coroner ruled her death could have been avoided. A criminal investigation into what happened at the trust is being carried out by West Mercia Police.
In her study, Ms Ockenden identified nine areas – and 60 actions – for learning and improvement at the trust, including management of patient safety, patient and family involvement in care and investigations, complaints processes, and staffing. In addition, 15 “immediate and essential actions” for all maternity services in England are put forward, covering 10 key areas, including that NHS England must commit to a long-term investment plan to ensure the “provision of a well-staffed workforce”.
The report added that appropriate, minimum staffing levels must be agreed nationally and locally, and adhered to, while there should be a clear escalation policy when staffing levels are not met. Furthermore, every trust should also have a patient safety specialist for maternity services, while “meaningful” incident investigations should happen, with proof of learning six months later.
Other actions include all trusts having consultants review postnatal readmissions, while bereavement services must be available seven days a week. Some £127million has been committed by NHS England for maternity services but the report said this is “still significantly short” of the £200-£350million recommended by MPs in 2021.
Ms Ockenden said: “A death of a mother or baby, or a birth incident which results in an injury should never be ignored. “There should never again be a review of this scale, in both numbers, and the length of years across which these concerns remained hidden.”
