More than 200 babies and 9 mums needlessly died in biggest maternity scandal in NHS history, damning report reveals

DOZENS of mums and babies died in two decades of medical failures at scandal-hit NHS hospitals, a damning report revealed today.

Some 201 babies and nine mothers needlessly died at Midlands hospitals in the biggest maternity scandal in NHS history.

An inquiry by top midwife Donna Ockenden today lifted the lid on a litany of devastating errors at the Shrewsbury and Telford Hospital NHS Trust.

It found maternity units were short-staffed for years and bosses refused to take responsibility for mistakes.

Alongside the tragic deaths, 94 babies suffered life-changing brain injuries as a result of “catastrophic” care.

As she spoke about the findings this morning, Ms Ockenden started by paying tribute to the families who suffered losses or life-changing injuries.

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The former midwife hailed the fact "the voices of families are now finally being heard".

She slammed the maternity services as having "failed", adding: "This is a trust that failed to investigate, failed to learn, and failed to improve.

"This resulted in tragedies and life changing incidents for so many of our families."

The report looked at more than 1,800 complaints at the Midlands hospitals, with most from between 2000 and 2019.

It found 40 per cent of stillbirths had not been investigated by the trust, similarly with 43 per cent of neonatal deaths.

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The top midwife said: "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.

“Going forward, there can be no excuses, Trust boards must be held accountable for the maternity care they provide.

"The trust was of the belief that it's maternity services were good – they were wrong."

She added concerns were "not unique" to the trust in her review, with an overhaul required in mum-and-baby units all over England.

The investigation was launched after bereaved families doggedly campaigned for a probe into the errors.

It led staff members to come forward and paint a picture of a "clique with a culture of undermining and bullying", where concerns were ignored by bosses.

And Ms Ockenden revealed maternity staff had contacted the review team only this month over worries they still have about care on the wards.

One sent an emotional message to the parents, which the top midwife delivered, saying: "I am sorry and I know that sorry is not enough but by engaging with this review but we hope that our voices will finally be acknowledged to change will happen."

CARE COMPLAINT

The report found families were often treated badly – echoed in women's medical records, in documents provided to the inquiry by the trust and families, and in letters sent to families by the trust.

Target numbers for “natural” vaginal births meant women were denied or had delayed C-sections, increasing risks, the report found.

In some cases, women were blamed for losing their babies, while others had their concerns and complaints dismissed, compounding their grief at losing a child.

Ms Ockenden added many families have come forward as recently as last year to complain about the care they got at the trusts.

Tory MP Jeremy Hunt, who in 2017 ordered the Ockenden inquiry into mother and baby deaths at Shrewsbury when he was health secretary, said the numbers were "worse" than he could have imagined at the start of the process.

He told the BBC Radio 4 Today programme that initially there were 23 instances of concern.

He added: "This report, from what I've been able to glean, I haven't seen it myself, is very, very shocking and sobering reading."

He said he hopes it is "a wake up call", adding: "I think the families have played a really extraordinary role, but we have to ask ourselves, is it morally right that we need families to have to campaign over decades to get to the truth as to why their child died, rather than the NHS itself being really hungry to learn from mistakes, to put them rights, to make sure that processes are changed so these tragedies don't happen again?"

In her interim report in December 2020, former senior midwife Ms Ockenden described how, in 2011, a woman was in agony but was told that it was "nothing", while staff were dismissive and made her feel "pathetic". One obstetrician was abrupt and called her "lazy".

'WAKE UP CALL'

Health and Social Care Secretary Sajid Javid said: “Donna Ockenden’s report paints a tragic and harrowing picture of repeated failures in care over two decades, and I am deeply sorry to all the families who have suffered so greatly.

“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.

“I would like to thank Donna Ockenden and her whole team for their work throughout this long and distressing inquiry, as well as all the families who came forward to tell their stories.”

One of the parents affected is Shropshire mum Charlotte Cheshire, 44.

Her son was left with severe health problems because medics were too slow to treat a bacterial infection.

PARENTS' PAIN

The reverend from Newport, Shropshire, says her son Adam, now 11, looked unwell after his birth in 2011 but her concerns were dismissed by staff at the trust.

When it was finally discovered that he had Group B Strep infection, he was rushed to intensive care where he stayed for almost a month.

She said: “What I'm ultimately hoping is that all of the families get some answers.

"And then, in our individual cases, about how it's possible for there to be such systemic failings over so many years, with seemingly either no-one noticing them, or potentially them being covered up.

"So I'm hoping first of all for answers, but secondly, I'm hoping, as a result of Ockenden, there are genuine learnings.

"Not the sort of, 'oh, we'll learn and get back to you', but genuine learnings to improve maternity safety – primarily first of all at Shrewsbury and Telford, but secondly across the country as a whole.

"I don't want any other family to have to go through what we've gone through."



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.

Another couple in the campaign for safer care are Kayleigh and Colin Griffiths.

Their daughter Pippa died in 2016 from a Group B Strep infection. A year later, a coroner ruled her death could have been avoided.

A criminal investigation into what happened at the trust is being carried out by West Mercia Police.

An interim report from the inquiry, published in December 2020 and covering 250 reviews, found a string of failings over two decades.

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There was an unwillingness by Shrewsbury and Telford Hospital NHS Trust to learn lessons from its own inadequate investigations, leading to babies being born stillborn, dying shortly after birth or being left severely brain damaged.

Several mothers also died due to apparent failings of care.


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