Baby deaths inquiry: Shrewsbury NHS trust condemned for ‘repeated failures’

A damning report into hundreds of baby deaths has condemned the trust at the centre of the biggest maternity scandal in the history of the NHS for blaming mothers while repeatedly ignoring its own catastrophic blunders for decades.

The independent inquiry into maternity practices at Shrewsbury and Telford hospital NHS trust uncovered hundreds of cases in which health officials failed to undertake serious incident investigations, while deaths were dismissed or not investigated appropriately. Instead, grieving families were denied access to reviews of their care and mothers were blamed when their babies died or suffered horrific injuries.

A combination of an obsession with natural births over caesarean sections coupled with a shocking lack of staff, training and oversight of maternity wards resulted in a toxic culture in which mothers and babies died needlessly for 20 years while “repeated failures” were ignored again and again.

Tragically, it meant some babies were stillborn, dying shortly after birth or being left severely brain damaged, while others suffered horrendous skull fractures or avoidable broken bones. Some babies developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries.

The report, led by the maternity expert Donna Ockenden, examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents.

“Throughout our final report we have highlighted how failures in care were repeated from one incident to the next,” she said. “For example, ineffective monitoring of foetal 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 lifelong 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 and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding. Going forward, there can be no excuses.”

The inquiry was ordered by Jeremy Hunt in 2017 when he was health secretary. On Wednesday, he said the numbers were “worse” than he could have imagined and he hoped the report would be “a wake-up call”.

Ockenden’s team of investigators found families were locked out of reviews into deaths and were mistreated by callous maternity staff.

The trust, which is now ranked inadequate, repeatedly failed to adequately monitor baby’s heart rates, with catastrophic results, alongside not using drugs properly in labour. Trust leaders and midwives also pursued a lethal strategy of deliberately keeping caesarean section rates low, despite the fact this repeatedly had severe consequences.

Richard Stanton and Rhiannon Davies, who have campaigned for years over the poor care they experienced, lost their daughter Kate within hours of her birth in March 2009. The trust described it as a “no harm” event, but an inquest jury later ruled Kate’s death could have been avoided. The trust continued to insist its care had been in line with national guidelines.

A second couple who have led the campaign for safer care at Shrewsbury are Kayleigh and Colin Griffiths, whose daughter Pippa died in 2016 from a Group B strep infection. A year later, a coroner ruled her death could have been avoided.

A criminal investigation into the trust is being carried out by West Mercia police.

Ockenden identified nine areas – and 60 actions – for learning and improvement at the trust, including management of patient safety, patient and family involvement in care and investigations, complaints processes, and staffing.

The report says appropriate, minimum staffing levels must be agreed nationally and locally, and adhered to, while there should be a clear escalation policy when staffing levels are not met. Health leaders told the Guardian this week they fear a national shortage of more than 2,000 midwives means women and babies will remain at risk of unsafe care in the NHS.

“A death of a mother or baby, or a birth incident which results in an injury should never be ignored,” said Ockenden. “There should never again be a review of this scale, in both numbers, and the length of years across which these concerns remained hidden.”

Source: The Guardian