It has been five years in the making. The independent inquiry into the largest maternity scandal in the history of the NHS began with one grieving mother looking for answers and ended up involving 1,486 families and 1,592 clinical incidents.
The deeply distressing story of Shrewsbury and Telford hospital NHS trust, where hundreds of babies needlessly died or suffered life-changing injuries, is well known. Even so, when the final 234-page report by Donna Ockenden was published at 10am on Wednesday, the details shocked many of those reading it.
Among them was the former health secretary, Jeremy Hunt, who commissioned the inquiry after being approached by Rhiannon Davies and others affected by poor care at Shrewsbury. The findings of Wednesday’s report were “far worse” than he could ever have imagined, he said.
The report is harrowing. It describes in detail for the first time how 201 babies and nine mothers could have or would have survived if the trust had provided better care.
Ockenden found the trust presided over catastrophic failings for two decades – and did not learn from its own woefully inadequate investigations – which led to more babies being stillborn, dying shortly after birth or being left severely brain damaged.
Much has been made of how some women were forced to have “natural births” despite the fact they should have been offered a caesarean. Indeed, Ockenden found that for 20 years the caesarean section rate at the trust was consistently 8% to 12% below the English average. Incredibly, this was held up locally and nationally as a good thing.
However, the suggestion by some that the focus on “natural births” was the main cause of the scandal is misplaced. Indeed, the final report makes this clear. Instead, the deadly tragedy at Shrewsbury was the result of a toxic cocktail of issues.
Staff were “overly confident” in their ability to manage complex pregnancies, and there was a culture of “them and us” between midwives and obstetricians, which meant some midwives were scared to involve consultants. Investigators found “repeated failures” to escalate concerns, delays in women being admitted to labour wards, and delays to women being assessed for emergency intervention. NHS staff also repeatedly failed to adequately monitor babies’ heart rates, with catastrophic results, alongside not using drugs properly in labour. A lack of staff, a lack of training, and a lack of oversight or sufficient concern from trust leaders were also to blame.
Tragically, many of these issues remain a persistent problem in maternity services across England. Shrewsbury is not alone. Morecambe Bay, East Kent and Nottingham hospitals have all had poor maternity care exposed in recent years. Naturally, this prompts the question of what needs to change if these scandals are to be avoided elsewhere.
Ockenden has raised 15 areas for “immediate and essential action” to improve care and safety in maternity services across England. Areas such as accountability, clinical governance and robust support for families have all been included as “must dos”.
One of the key areas that needs to improve is staffing levels. The report said maternity and neonatal services in England required a multi-year settlement from NHS England “to ensure the workforce is enable to deliver consistently safe” care. However, health leaders have told the Guardian that the current shortage of more than 2,000 midwives means that women and babies will, for now, remain at risk of unsafe care.
More widely, the NHS must demonstrate an ability to admit to mistakes and learn from them, and promote a culture of openness.
Five years ago, this journalist was in Shrewsbury investigating the baby deaths when a board meeting of the trust was held in the town. Simon Wright, then the chief executive, told those present he was “committed to being candid and open about any incident” while refusing to answer any questions about the emerging scandal.
One woman told Wright his behaviour was “utterly disgraceful”. And when demands for the board’s non-executive directors to question Wright were met with silence, members of the public chanted “Shame on you, shame on you”.
But that wasn’t the worst of it. The board arrived at the meeting accompanied by two security men. Afterwards, a mother whose baby girl died after failures at the trust said: “Isn’t it a shame our babies weren’t offered the same level of safety?”
