An independent review at a hospital trust shows mums were blamed for deaths of their babies in NHS’s worst ever hospital maternity scandal.
The damning report, released today, found 13 mothers died between 2000 and 2019 in the care of Shrewsbury and Telford Hospital NHS Trust.
Others were called pathetic and lazy or left screaming for hours without treatment.
In one horrendous case, a woman had repeated attempts at forceps delivery but the baby sustained multiple skull fractures and subsequently died.
It does not say how many babies died or suffered serious injury, but between 2013 and 2016, maternity death rates were 10 per cent higher than in comparable hospital trusts.
The report identifies seven “immediate and essential actions” needed to improve maternity care in England.
The inquiry into deaths and allegations of poor care at the hospital trust was set up in 2017 and is now examining the cases of 1,862 families, with the majority of incidents occurring between 2000 and 2019.
In a press conference following the release of the review, former senior midwife Donna Ockenden, chair of the independent maternity review, said mothers had been “denied the opportunity to voice their concerns about the care they have received … for a long, long time”.
She said the care at the trust had “caused untold pain and distress, including, sadly, deaths of mothers and babies”.
She added: “Many families have suffered long-term mental health problems.
“They say their suffering has been made worse by the handling of their cases by the trust.”
She said “one of the most disappointing and deeply worrying themes” was the “reported lack of kindness and compassion from some members of the maternity team at the trust”.
The chief executive of the trust apologised for the “pain and distress” caused to mothers and families due to poor maternity care – after the review found staff had been “flippant”, “abrupt” and “dismissive”.
The damning 48-page report found:
- A lack of compassion and kindness from some maternity staff
- Concerns of families about their care were dismissed and not listened to
- Midwives failed to recognise when pregnancies were not progressing normally
- Repeated failures to communicate problems to senior staff
- Inappropriate use of drugs, including oxytocin, to speed up labour
- Errors in monitoring the heartbeats of babies
- A culture of reducing the number of caesarean births without considering if it was causing harm
The “emerging findings” report was published on Thursday, based on a review of a selection of 250 cases of concern, which include the original 23 cases which initiated the inquiry.
Ms Ockenden described the initial recommendations – including a call for risk assessments throughout pregnancy – as “must dos” which should be implemented immediately.
Responding to the report, patient safety and maternity minister Nadine Dorries said she expects SaTH to act on the recommendations immediately following “shocking” failings at the trust.
Ms Dorries said in a statement: “My heartfelt sympathies are with every family who has been affected by the shocking failings in Shrewsbury and Telford Hospital NHS Trust’s maternity services.
“I would like to thank Donna Ockenden and her team for their hard work in producing this first report and making these vital recommendations so lessons can be learnt as soon as possible.
“I expect the trust to act upon the recommendations immediately, and for the wider maternity service right across the country to consider important actions they can take to improve safety for mothers, babies and families.
“This Government is utterly committed to patient safety, eradicating avoidable harms and making the NHS the safest place in the world to give birth.
“We will work closely with NHS England and Improvement, as well as Shrewsbury and Telford Hospital NHS Trust, to consider next steps.”
Commenting on her initial findings, Ms Ockenden said: “Over the last three years, this independent review team has been listening to and working with families and the trust in order to try and understand what happened.
“We have been listening so that we can enable the trust and wider maternity services across England to be clear about the improvements needed.
“This will ensure that maternity services are enabled to continuously improve the safety of the care they provide to women and families.
“Today we are explaining in this first report local actions for learning and immediate and essential actions which we believe will improve maternity care, not only at this trust but across England so that the experiences women and families have described to us are not replicated elsewhere.
“With a focus on safety, the 27 local actions for learning and seven immediate and essential actions in this report are ‘must dos’ that need to be implemented now at pace.”
The inquiry was commissioned following concerns raised by the parents of Kate Stanton-Davies and Pippa Griffiths, who died shortly after birth in 2009 and 2016 respectively.
This report found both of their deaths as “avoidable”.
Parents of Kate, Rhiannon Davies and Richard Stanton, lost their daughter Kate at just six-hours-old after woefully poor care was afforded to her.
An inquest held in November 2012 found that Kate’s death was avoidable, a finding that the trust chose to ignore.
West Mercia Police have also launched their own investigation to establish if there are any grounds for criminal proceedings.
The 27 local actions for learning involve recommendations around general maternity care, maternal deaths, obstetric anaesthesia and neonatal care.
Louise Barnett, chief executive at Shrewsbury and Telford Hospital NHS Trust, said: “I would like to thank Donna Ockenden for this report but more importantly the families for coming forward.
“As the chief executive now and on behalf of the whole trust, I want to say how very sorry we are for the pain and distress that has been caused to mothers and their families due to poor maternity care at our trust.
“We commit to implementing all of the actions in this report and I can assure the women and families who use our service that if they raise any concerns about their care, they will be listened to and action will be taken.”