Shrewsbury maternity scandal: ‘Unimaginable trauma’ caused, says Javid as report details avoidable baby deaths

The inquiry findings into the UK’s biggest maternity scandal are out.

It says there were a total of 295 avoidable baby deaths or brain damage cases as a result of poor maternity care between 2000 and 2019 at Shrewsbury and Telford Hospital NHS Trust.

Broken down, this was 131 stilibirths, 84 brain damage cases and 70 neonatal deaths.

Mothers and babies died or suffered major injuries due to “repeated failures” by the trust, who presided over catastrophic failings for 20 years and did not learn from its own inadequate investigations, according to the inquiry.

Several mothers died after failings in care, while others were made to have natural births despite the fact they should have been offered a Caesarean.

Some babies suffered skull fractures, broken bones or developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries.

Here is what Donna Ockenden said:

“Throughout our final report we have highlighted how failures in care were repeated from one incident to the next.

“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 life-long 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.”

The inquiry reviewed 1,592 clinical incidents involving mothers and babies spanning between 2000 and 2019.

Donna Ockenden said she was “deeply concerned” that families continue to contact the review team in 2020 and 2021 raising concerns about the safety of maternity care they have received at the Shrewsbury and Telford Hospital NHS Trust.

“Some of these recent families contacted us with reports they wanted to share with us. We haven’t been able to include them fully within the review but what we have seen is that the themes within their reports seem to echo concerns we have previously seen during this review.

“Seeing these repeated themes is a cause for grave concern.”

Here are the key findings:

• 131 stillbirths, 70 neonatal deaths and 84 cases of brain damage in babies occured due to poor maternity care
• Nine mothers died as a result of avoidable poor care
• Babies died due to a culture of “reluctance to perform caesarean sections”
• Traumatic forceps deliveries caused skull fractures, broken bones or development of cerebral palsy in babies
• Staff were “overly confident” in their ability to manage complex pregnancies or where abnormalities were noted

Rebecca Thomas, our health correspondent, has the full story:

Donna Ockenden said the maternity services at the trust “failed both families across Shropshire, and sometimes their own staff, over a prolonged period of time”.

She said “four key pillars” have been identified to improve maternity services at the trust and across England: safe staffing levels properly funded, a well-trained workforce, learning from incidents and listening to families.

The maternity expert told a press conference there must be a “fully funded and then concerted effort” by NHS trusts to make these “the foundation, the road map, and the blueprint of all maternity services going forward”.

Louise Barnett, chief executive at the Shrewsbury and Telford Hospital NHS Trust said: “Today’s report is deeply distressing, and we offer our wholehearted apologies for the pain and distress caused by our failings as a trust.

“We have a duty to ensure that the care we provide is safe, effective, high quality, and delivered always with the needs and choices of women and families at its heart.

“Thanks to the hard work and commitment of my colleagues, we have delivered all of the actions we were asked to lead on following the first Ockenden report, and we owe it to those families we failed and those we care for today and in the future to continue to make improvements, so we are delivering the best possible care for the communities that we serve.”

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Sajid Javid, the health secretary, has called the inquiry a “tragic and harrowing picture of repeated failures in care over two decades”.

“I am deeply sorry to all the families who have suffered so greatly,” he said.

“Since the initial report was published in 2020 we have taken steps to invest in maternity services and grow the workforce, and we will make the changes that are needed so that no families have to go through this pain again.”

Sajid Javid, the health secretary, says he will give a statement in parliament later today in light of the inquiry:

The inquiry looked at cases involving hundreds of families.

Here are some of the stories behind them: