The report following investigations into concerns about maternity care provided at Shrewsbury and Telford Hospital NHS Trust (the Trust) has finally been published today.
As we recently reported, the investigations into the maternity care services at the Trust came about when two mothers, who had lost their babies as a result of poor care, joined forces to find other women who had been similarly affected by carrying out a search of the internet, coroner’s records, and death notices. They took their concerns to Jeremy Hunt who, in May 2017, ordered an investigation of the maternity care services at the Trust to take place.
The extensive investigation, led by Donna Ockenden, a Senior Midwife, looked at over 1,800 cases spanning 20 years. It is thought to be the largest of its kind in NHS history.
The published report confirms that more than 200 babies may have died and many others left with life-changing injuries as a result of repeated failures at the Trust.
The review confirmed that 201 babies could have survived if the Trust had provided better care. There were also 29 cases of severe brain injuries and 65 cases of cerebral palsy.
Ms Ockenden added that the Trust had a tendency to blame mothers for poor outcomes, even in some cases for their own babies’ deaths.
In total, the report identifies 60 areas where improvements could be made at the Trust.
The main findings of the report are:
- There was a culture at the Trust where mistakes were not investigated and a failure of external scrutiny. It was noted that between 2011 and 2019, 40% of stillbirths and 43% of neonatal deaths did not undergo any investigation;
- Parents were not listened to when they raised concerns about the care they received;
- Where cases were examined, responses were described as lacking “transparency and honesty“;
- The Trust failed to learn from its mistakes, leading to repeated and almost identical failures;
- There was a culture of bullying, anxiety, and fear of speaking out among staff at the Trust “that persisted to the current time”;
- Caesarean sections were discouraged, often leading to poor outcomes.
Health Secretary Sajid Javid said that he was “deeply sorry to all the families who have suffered so greatly.” Adding “We will make the changes that are needed so that no families have to go through this pain again.”
The report has advised that increased funding, training, and accountability across maternity services as well as improved post-natal care and care for bereaved families is required.
The Chief Executive at the Trust said the report was “deeply distressing.”
Louise Barnett, Chief Executive at the Trust said:
“We offer our wholehearted apologies for the pain and distress caused by our failings as a Trust…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.”
Comment
This report makes for incredibly difficult reading, and it is unimaginable what these families have been through. It’s important to refer to the report’s clear message that its themes are not restricted to the one Trust, but should be shared across England to bring about urgent and necessary changes across maternity services.
In the Acknowledgements section of the report, Ms Ockenden said that this was a “once in a generation opportunity to improve the safety and quality of maternity service provision for families across England, now and in the future.” I very much hope this will come to pass, but in order for it to happen the lessons from Shrewsbury and Telford Hospital NHS Trust need to be learned across the NHS, but most particularly in places where there appear to be patterns of the same safety issues arising again and again (such as at Nottingham University Hospitals NHS Trust).
The investigation has clearly been a full and thorough review of the concerns and the resulting report is a testament to the strength and hard work of the mothers who came together and took their concerns forward back in 2017.
There is clearly a lot of work to do for the Trust. The findings of the investigation are shocking and horrific, and regaining trust in future patients and families will no doubt be a battle. It is imperative that the Trust stops and ensures that every recommended step is followed to the letter to ensure this never happens again.
Lessons must be learned and changes must be intrinsic to the Trust’s policies and procedures moving forward. It is the absolute bare minimum the Trust owes these families, and all those families yet to set foot through their doors.
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Danielle Young is a Senior Associate in our Medical Negligence team, which has been ranked in tier one by the independently researched publication, The Legal 500. Our team has frequently been instructed on cases involving the incredibly sad death of a child.
If you have any questions in relation to the subjects discussed in this article, then please get in touch with Danielle or another member of the team in Derby, Leicester or Nottingham on 0800 024 1976 or via our online form.
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