Shrewsbury maternity scandal: Repeated failures led to deathson March 30, 2022 at 9:28 am

More than 200 babies may have died and many others left with life-changing injuries due to repeated failures at an NHS Trust, a report has found.

Senior midwife Donna Ockenden’s review examined catastrophic failures in maternity care at the Shrewsbury and Telford NHS Trust (SaTH).

It said “failures in care were repeated from one incident to the next”.

The review examined almost 1,600 cases spanning 20 years and is thought to be largest of its kind in NHS history.

SaTH has previously said it takes “full responsibility” for the failures and offered its sincere apologies to affected families.

It was revealed that 201 babies could have survived had SaTH provided better care, related to 70 neonatal deaths and 131 cases where babies were stillborn.

There were also 29 cases where babies suffered severe brain injuries and 65 incidents of cerebral palsy.

In all those cases, as well as nine mothers’ deaths, the inquiry found better care “might” or “would reasonably be expected” to have made a difference.

Ms Ockenden cited examples of ineffective monitoring of foetal growth and a culture of reluctance to perform Caesarean sections as repeated problems which “resulted in many babies dying during birth or shortly after”.

“The reasons for these failures are clear,” she said. “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.”

In all, she identified 60 areas where improvements could be made at SaTH and said there could be “no excuses” going forward.

The review found an culture of not investigating mistakes, with hundreds of instances where SaTH failed to appropriately examine deaths or undertake serious incident investigations with mistakes being “inappropriately downgraded”.

When cases were investigated, the trust failed to identify areas for improvement and missed opportunities to learn.

Ms Ockenden added the trust had a tendency to blame mothers for poor outcomes, and even in some cases for their own babies’ deaths.

The inquiry was first commissioned in 2017 following a campaign by two families who had lost their babies.

Richard Stanton and Rhiannon Davies’s daughter Kate died hours after her birth in March 2009, while Kayleigh and Colin Griffiths’ daughter Pippa died in 2016 from a Group B Streptococcus infection.

Ms Davies said the number of deaths “do not tell the whole story” of the impact on families.

“I think you really must dig into the family details to understand the long-term, deep-seated pain and harm that has been meted out by such appallingly poor care at this trust,” she said.

The review calls for increased funding, training and accountability across maternity services as well as improved post-natal care and care for bereaved families.

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