(Picture: PA Archive)
A national review of maternity care was demanded on Wednesday after an inquiry found many babies died at a NHS trust or were left-brain damaged because of inadequate pregnancy checks and a reluctance to perform caesareans.
The review into Shrewsbury and Telford Hospital NHS Trust investigated 1,592 clinical incidents involving 1,486 families between 2000 and 2019, though the earliest case dates to 1973. Some families suffered more than once.
More than 200 babies and nine mothers died as a result of failings, the report said. A further 94 babies suffered brain damage.
The mothers 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.
Tory MP Jeremy Hunt, who ordered the inquiry in 2017 when he was health secretary, said the numbers were “worse” than he could have imagined and hoped the report would be “a wakeup call”.
Health Secretary Sajid Javid said: “Donna Ockenden’s report paints a tragic and harrowing picture of repeated failures in care over two decades, and I am deeply sorry to all the families who have suffered so greatly.
“Since the initial report was published in 2020 we have taken steps to invest in maternity services and grow the workforce, and we will make the changes that are needed so that no families have to go through this pain again.”
Report author Donna Ockenden there was a failure to listen to families, to learn from incidents and of many external bodies to intervene at the trust.
There were hundreds of cases where the trust failed to undertake serious incident investigations, with some deaths not being examined appropriately. The report is the largest-ever inquiry into a single service in NHS history.
Ms Ockenden said: “Failures in care were repeated from one incident to the next. For example, ineffective monitoring of fetal 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.”
She demanded “15 immediate and essential actions” for all maternity services in England, including the requirement for NHS England to fund a “well-staffed workforce” and minimum staffing levels in maternity units.
She said last week’s funding announcement of £127m by NHS England for maternity services fell “significantly short” of the £200-£350m amount recommended by the Commons health and social care committee.
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.
Steve Turner, of the Royal College of Paediatrics and Child Health, said: “It is shocking that clinical and managerial staff felt unable to speak out about what was happening for fear of retribution.”
