Shrewsbury maternity scandal: Inquiry demands NHS overhaul to prevent baby deaths

Maternity care across the NHS must be urgently overhauled to prevent widespread malpractice that puts mothers and babies at risk, according to a damning inquiry into the largest scandal of its kind in the history of the health service.

There were dozens of deaths at Shrewsbury and Telford Hospital Trust over several decades because of a drive to avoid caesarean sections, even denying women key information about the risks, the first official report of the independent inquiry, which is examining more than 1,860 family complaints, found.

This culture saw mothers given drugs to increase the strength and frequency of their contractions, putting babies at risk of brain damage and death. Some were then forced to undergo traumatic deliveries in which the level of “excessive force” fractured babies’ skulls and broke their bones.

The inquiry, led by midwife Donna Ockenden, warned that hospitals must ensure women are listened to when deciding on their maternity care and when they raise concerns.

In Shrewsbury, it found mothers had been subjected to a lack of kindness and compassion by staff, with some parents being blamed for what happened to their babies, while incidents of poor care were not properly investigated by the trust, meaning failures were repeated.

Full story: Babies’ skulls fractured and bones broken in traumatic births

Rhiannon Davies, whose daughter Kate died following a series of mistakes in 2009, spent years campaigning to prompt the inquiry. She said: “These people have caused death. These have caused catastrophic harm. They have caused untold suffering. They have no place in healthcare.

“There can be no more complacency. The time is now for significant deep-seated changes across maternity.”

Last year The Independent revealed the scale of poor care at the trust which has been rated inadequate by the Care Quality Commission and which is also facing a criminal investigation into the maternity deaths and actions by trust bosses.

The latest report said changes were needed nationally “as a matter of urgency” to make maternity units safer. It said: “We strongly believe we have identified a need for structural changes which, if implemented nationwide with our recommendations, will reduce cases of harm to mothers and babies.”

Kayleigh Griffiths, whose daughter Pippa died in 2016 after midwives failed to spot a deadly infection, told The Independent she welcomed the report adding: “We are in 2020, what sort of trust needs to be told to be kind and compassionate? The trust seems to be working in silos and against the patients.”

Ms Griffiths, who has worked in the NHS herself, added she wanted to see better monitoring of hospitals’ performances.

“It’s very easy to pull the wool over people’s eyes. You can make things look better for a few hours but we need much more robust systems of oversight. How was this allowed to happen for so many years?”

Since the revelations over Shrewsbury, parents whose children died have raised concerns about maternity care at units including East Kent Hospital Trust, itself now subject to an inquiry, Basildon hospital in Essex and Morecambe Bay in Cumbria, which was previously investigated over deaths between 2004 and 2013. The CQC has warned one in three units need to improve on safety, while the Health and Social Care Select Committee, led by former health secretary Jeremy Hunt, is carrying out its own investigation into national maternity care. 

Mr Hunt, who set up the Shrewsbury inquiry in 2017, said: “There is nothing more cruel in life than losing a child – but to do so because of mistakes that were covered up makes things infinitely more painful.

“What is more shocking, though, is the scale and longevity of this scandal. We now know it forms a pattern with problems at other trusts including Morecambe Bay, East Kent and potentially other places too on a scale that was unimaginable when I commissioned the review in 2017. 

“This report must not be allowed to gather dust. Yes, ministers are busy with Covid, but this sobering report must be a very high priority for Matt Hancock.” 

The report said NHS hospitals should be forced to work together on serious incidents, with the deaths of mothers and babies, as well as brain injuries, examined by regional experts as part of local networks, while regional hubs could provide expert advice.

It said: “This is essential to ensure that effective learning and impactful change to improve patient safety in maternity services can take effect using a system-wide approach and in a timely manner.”  

The report said women’s voices must be heard in maternity services by a named non-executive director on their board responsible for promoting women’s voices, adding the Care Quality Commission should assess how well women’s views are considered in care when it inspects hospitals. 

The Independent has launched a campaign with charity Baby Lifeline for the resintatement of a national maternity safety training fund. The government has promised £9.4million for new training in some specific areas.

The inquiry report on Thursday recommended training funds be ringfenced and protected.

Judy Ledger, founder of Baby Lifeline, told The Independent the findings were “not unique” adding: “These and the hundreds of others I have come across in my decades of campaigning with Baby Lifeline again highlight the need for our professionals to be better supported to give the very best care they can to mothers and babies.  

“Baby Lifeline delivered a petition to reinstate the Maternity Safety Training Fund to Downing Street earlier this year with The Independent – the petition was signed by Donna Ockenden herself, as well as representatives from the Royal College of Obstetricians and Gynaeologists and Royal College of Midwives. Despite this, the spending review failed to allocate money towards a training fund, and failed to recognise the importance of this as a step towards improving maternity safety. We hope that this will be reconsidered.”

Donna Ockenden, chair of the inquiry, said she believed the recommendations would help improve care across England “so that the experiences women and families have described to us are not replicated elsewhere”.

She added the actions set out in her report were “must dos that need to be implemented now at pace”.

She paid tribute to the families who had campaigned for the inquiry saying: “This must include the very many families who tried to raise serious concerns about maternity care at the trust who have told us they were not listened to.”

The inquiry was commissioned to look at 23 cases of poor care. It was widened in 2018 after dozens more cases were identified, with a full final report expected to be published in 2021.

Nadine Dorries, the minister for patient safety, said the government would work with NHS England to consider next steps, adding: “This government is utterly committed to patient safety, eradicating avoidable harms and making the NHS the safest place in the world to give birth.”

Louise Barnett, chief executive at The Shrewsbury and Telford Hospital NHS Trust, said: “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.”

“If you are pregnant and have any questions about your current care, please contact your midwife.”