Shrewsbury maternity scandal: Key findings from damning Ockenden inquiry report

Shrewsbury and Telford Hospital NHS Trust presided over catastrophic failings for 20 years, a report into the largest maternity scandal in NHS history has found.

The inquiry, led by senior midwife Donna Ockenden, delivered a scathing verdict on the trust’s quality of care, concluding that it did not learn from its own investigations, which in turn led to babies being stillborn, dying shortly after birth or being left severely brain damaged.

Several mothers were made to have natural births despite the fact they should have been offered a caesarean.

The inquiry’s report, published today, delivered a number of key findings:

The inquiry covered 1,592 clinical incidents involving 1,486 families between 2000 and 2019, during which time it found there were more than 200 avoidable baby deaths or brain damage cases as a result of poor maternity care, including 131 stillbirths, 70 neonatal deaths and 84 cases of brain damage.

It said nine mothers had also died as a result of avoidable poor care. Concerns were raised about a further three deaths, although it was determined care had not been a factor in these outcomes.

In some cases, fault was placed on mothers for the death of their baby, while others had concerns and complaints dismissed – compounding their grief at losing a child.

Babies also died during birth and shortly after due to a culture of a “reluctance to perform caesarean sections”, the report found.

Ms Ockenden said staff had spoken of a “republic of maternity”, which disliked corporate oversight, while others spoke of chaos and being ignored by more senior staff.

She said they “describe a clique on the labour ward at the trust with a culture of undermining and bullying”.

Confirming that concerns had been expressed by staff within the past month, Ms Ockenden said: “We spoke to staff members of the trust, and documentary evidence also considered by the review team, showed us that following serious incidents, there would be no follow-up from recommendations made.

“One staff member told us this wasn’t just the maternity unit in chaos and under pressure – this was a whole organisation where it was difficult to find an area which was not under pressure.

“Another member of staff told us there was a ‘republic of maternity’, but often the maternity service seemed to consume its own smoke and didn’t like having oversight by the corporate team.

Ms Ockenden said her team were still “very concerned” that in recent weeks staff still working at the trust have come forward to express their concerns about the trust in the “here and now”.

Staff reported feeling “fearful” to speak out and were told not to take part in the inquiry.

One staff member speaking to the review team said: “I know multiple people that have not approached you to speak because of fear, because of how it was put in that briefing [from the trust to staff], there were people that had every intention of completing their survey and then after that, no way.

“I was like but this is your chance to speak. How can you make any changes? How can you do anything about it when we’re given this opportunity but they’re still working there? I think they were perhaps fearful of their jobs, I don’t know.”

Ms Ockenden said families have continued to contact the inquiry in 2020 and 2021 with concerns about maternity care with similar failings seen in older cases, added that this is a “cause for grave concern”.

Richard Stanton and Rhiannon Davies, who have campaigned for years over poor care, lost their daughter Kate hours after her birth in March 2009.

The trust noted her death but described it as a “no harm” event, although an inquest jury later ruled Kate’s death could have been avoided. The trust still insisted its care had been in line with national guidelines.

In her final report, Ms Ockenden said there was evidence of poor investigation into the deaths of two other babies, Joshua and Thomas, who died within the same year before Kate in similar circumstances.

She said there was a lack of transparency and a “lost opportunity” to prevent further baby deaths occurring.

Kayleigh and Colin Griffiths’ daughter Pippa died in 2016 from a group B strep infection. A year later, a coroner ruled her death could have been avoided.

Fifteen immediate and essential actions were identified for the trust and nationally in the report.

Areas such as safe staffing, escalation and accountability, clinical governance and robust support for families have all been included as “must dos” by the document.

The actions included the call for a multi-year funding plan for maternity services. The funding should be in the region of £200m to £350m, which was previously estimated by the Health and Social Care Committee.

Protected time must be allocated for training across all maternity specialisms including routine refresher courses, the review said.

It also raised concerns over the “continuity of carer model” that requires mothers to receive care from the same midwifery team with a named midwife.

It said pressures on NHS resources were leading to concerns that the model can lead to inequality in provision and so the inquiry has asked for the model to be reviewed and suspended until all trusts can meet the minimum staffing requirements.

The mental health and wellbeing of mothers also forms part of the essential action, with partners and families as “integral” to all aspects of maternity service provision.

The document indicates every trust should have a “patient safety specialist” dedicated to maternity services, and that all leaders are trained in human factors such as family engagement.