Mothers were blamed for the deaths of their babies, while fatal health problems were ignored for decades, according to a scathing report on the biggest pregnancy scandal in the NHS.
The deficiencies investigation at Shrewsbury and Telford Hospital Trust found that 300 babies had died or suffered brain injuries as a result of poor care.
Maternity expert Donna Ockenden, who led the investigation, warned that maltreatment was still an issue at the trust, despite calls for immediate action following the initial findings in 2020.
Systemic issues at the trust were highlighted as early as November 2019 by Ms Ockendenas in her interim report, revealed by the independent† But she said the maternity staff had told her they were still concerned about the level of care today.
Families said they suffered “incomprehensible cruelty” because their concerns were not addressed and some deaths were not investigated.
Health Secretary Sajid Javid told the House of Commons on Wednesday that in one case, important clinical information had been kept on post-it notes, which were then discarded by cleaners.
The investigation into the cases of 1,486 families, which began in 2017, found:
- The trust “blamed” families after the deaths of their children
- Disruptions in care were repeated from one incident to another
- Traumatic forceps deliveries caused skull fractures, broken bones or the development of cerebral palsy in babies
- External bodies have not held trust to account and internally trust has not learned from assessments
- Babies died after women were refused cesarean sections because of a culture that wanted natural births
Ms Ockenden, chair of the review, said: the independent said she had had staff members say they were “afraid to speak out” and “afraid for their jobs” on Tuesday.
The chairman made it clear that there were ongoing concerns about care across the trusts, despite an initial review in 2020 calling for improvements.
Ms Ockenden said it was “astonishing” that for more than two decades the shortcomings had not been challenged internally by the trust and external health authorities had not held it accountable.
She made clear that there were lingering concerns about care at the trust, despite an initial assessment in 2020 calling for improvements, and also warned that the failures at Shrewsbury “could potentially be replicated elsewhere” outside of maternity care.
Case studies revealed more than 200 preventable deaths, including 131 stillbirths and 70 neonatal deaths. There were another 29 cases of severe brain damage and 65 cases of cerebral palsy. Nine women were also found to have died as a result of mistakes.
Parents Failed By Confidence Told the independent they suffered “inhumanity” and “incomprehensible cruelty” for being blamed for the deaths of their babies.
The families say they were not listened to and called for an independent council to examine the implementation of the recommendations by the hospitals.
Health Secretary Sajid Javid said the report was a “devastating record of rooms being empty, families being robbed and loved ones taken before their time”.
Mr Javid said Ms Ockenden’s actions would be accepted and offered assurances that those responsible for the “serious and repeated failures” would be held accountable.
The Ockenden review was first commissioned by former health secretary Jeremy Hunt in 2017 and originally involved 23 families.
in 2019 the independent revealed the review’s initial findings had identified more than a dozen women and more than 40 babies died during childbirth.
The review includes multiple reports from parents who said women were “blamed” or “held responsible” after women and babies were harmed or died.
Richard Stanton and Rhiannon Davies, whose daughter Kate died in March 2009, were one of the key families leading the campaign for justice.
According to the final Ockenden report, two babies died in similar circumstances in the year prior to Kate’s death.
Rhiannon Davies said there should be an independent whistleblower line for staff to speak out and a panel to review each year’s progress against the recommendations of the Ockenden report.
Kayleigh and Colin Griffiths, who were also at the forefront of the review, lost their daughter Pippa in 2016.
Speak with the independent they said: “We were not listened to and we were not listened to by the trust, and they keep telling us they learned and today showed us that although they tell us they have taken all the actions and the staff still comes out. They haven’t learned and until they do, we won’t be satisfied.”
Despite warnings from the assessment chair of lingering problems and that it had not implemented all of its previous recommendations, the trust’s chief executive, Louise Barnett, said on Wednesday that it had taken all steps requested of the company following its 2020 interim report.
“We know we need to do much more to ensure we provide the highest possible standard of care for the women and families we care for.”
Former Health Minister Jeremy Hunt said the “culture of fear in the NHS” has left it up to families to fight for justice.
Mr Hunt told the Commons: “Today’s report goes beyond my darkest fears when I appointed it as secretary of health in 2016.”
The latest Ockenden review identifies at least eight regulators and outside health agencies who have spent 20 years researching or highlighting care at Shrewsbury and Telford Hospitals Trust.
In 2021 senior NHS staff told reviewers they were aware of issues within the service from 2013 to 2020 but were assured by the confidence of changes, telling them they were “limited in their power to change things for the better” “.
Healthwatch England, whose chairman Sir Robert Francis led the public inquiry into failures in Mid Staffordshire, said the Ockenden report was “another scandal in which it is clear that no lessons have been learned from previous failures.”
The body’s national director, Louise Ansari, added: “We also know that the problems in maternity care do not stop at Shrewsbury Hospital as investigations have recently been conducted in other parts of the country into failing to provide safe care. to mothers and babies.”