The report found some babies suffered skull fractures, broken bones, or developed cerebral palsy (Photo: Adobe)
Shrewsbury and Telford Hospital NHS Trust presided over catastrophic failings for 20 years which resulted in babies being stillborn, dying shortly after birth or being left severely brain damaged.
Some 201 babies and nine mothers could have survived if the trust had provided better care, the inquiry found.
The report said some babies suffered skull fractures, broken bones, or developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen which led to life-changing brain injuries.
The trust, which is currently ranked inadequate, was also found to have repeatedly failed to adequately monitor baby’s heart rates, with catastrophic results, alongside not using drugs properly in labour.
Several mothers died due to failures in care, while others were forced to have natural births even though they should have been offered a Caesarean.
Investigators added that families were locked out of reviews when things went wrong and were often treated without compassion and kindness.
What did the report find?
The damning report, led by maternity expert Donna Ockenden, looked at cases involving 1,486 families between 2000 and 2018, and reviewed 1,592 clinical incidents.
The inquiry, which is the largest ever into a single service in the history of the NHS, was ordered by former Health Secretary Jeremy Hunt in 2017.
Mr Hunt said on Wednesday that the numbers were “worse” than he imagined and hoped the report would serve as “a wake up call”.
Hundreds of cases were identified in the inquiry where the trust had failed to undertake serious incident investigation, and found that deaths had not been investigated appropriately.
The report also said external bodies did not effectively monitor the level of care being provided.
Where investigations did take place, it was found they did not meet expected standards and failed to identify improvements, meaning no lessons were learned to avoid further serious incidents and harm.
Ms 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, mothers 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.
“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.”
Caesarean section rates were low
Health leaders and midwives were found to pursue a strategy of keeping Caesarean section rates low, despite the fact this repeatedly had severe consequences.
In an interim report published in December 2020, Ms Ockenden noted that for around 20 years the Caesarean section rate at the trust was consistently 8% to 12% below the England average, with this being held up locally and nationally as a good thing.
Her review team formed the clear impression there was a “culture” within the trust to keep Caesarean section rates low, as this was perceived as the “essence” of good maternity care in the unit.
David Redford, then a clinical director of women’s services in Shropshire, is on record telling several MPs in 2003 - some of whom praised low Caesarean rates - that “the culture of our organisation is that we have low intervention rates and, once that is known, we attract both midwives and obstetricians who like to practise in that way.”
Richard Stanton and Rhiannon Davies, who have campaigned for years over the poor care, lost their daughter Kate hours after her birth in March 2009. The trust noted the 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.
What did the report recommend?
Ms Ockenden identified nine areas – and 60 actions – for learning and improvement at the trust.
These include management of patient safety, patient and family involvement in care and investigations, complaints processes, and staffing.
In addition, 15 “immediate and essential actions” for all maternity services in England are put forward, covering 10 key areas, including that NHS England must commit to a long-term investment plan to ensure the “provision of a well-staffed workforce”.
The report added that 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.
It also said that every trust should have a patient safety specialist for maternity services and “meaningful” incident investigations should happen, with proof of learning six months later.
Other actions include all trusts having consultants review postnatal readmissions and bereavement services being available seven days a week.
Some £127million has been committed by NHS England for maternity services but the report said this is “still significantly short” of the £200-£350million recommended by MPs in 2021.
Ms Ockenden added: “A death of a mother or baby, or a birth incident which results in an injury should never be ignored.
“There should never again be a review of this scale, in both numbers, and the length of years across which these concerns remained hidden.”