Shrewsbury Hospital maternity scandal

Some 201 babies may have died at an NHS trust because of unprecedented failures, says report.

"It's down to the sheer determination and bravery of grieving families that these systemic failures have now been recognised. The numbers are enormous, shocking even for those of us who long suspected there was something far wrong with the care at the trust. Between 2011 and 2019, 40% of stillbirths and 43% of neonatal deaths did not even have an investigation. "The reasons for these failures are clear," she said. "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." "We will work with our partners across the health and care system to ensure that further improvements are made in light of this report, and will continue to take all actions necessary to ensure women who use our maternity services receive the best care." Ms Ockenden had earlier said staff were frightened to speak out about failings amid "a culture of undermining and bullying", with staff advised by trust managers not to take part in a "staff voices" initiative set up to assist the investigation into what went wrong. "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." "The legacy of this review should be a maternity service across England that is appropriately funded, well-staffed, trained, motivated and compassionate and willing to learn from failings in care," she said. Responding to the findings, current Health Secretary Sajid Javid said they painted a "tragic and harrowing picture of repeated failures in care". - A culture of bullying, anxiety and fear of speaking out among staff at the trust "that persisted to the current time" Ms Ockenden said: "We now know that this is a trust that failed to investigate, failed to learn and failed to improve.

The health secretary has said failures at an NHS hospital trust led to “unimaginable trauma for so many people” as a new inquiry shed light on the worst ...

Start your Independent Premium subscription today. But this report, from what I’ve been able to glean, I haven’t seen it myself, is very, very shocking and sobering reading.” It found more than a dozen women and more than 40 babies died during childbirth at the trust because of a culture that denied women choice and subjected hundreds of families to unsafe care. Back in 2020, the chief inspector of hospitals shared a litany of concerns over the standards of care at Shrewsbury and Telford Hospital Trust in a letter to NHS England. This is because the final report of the inquiry into the largest maternity scandal ever seen within the NHS is set to published and reveal failings in the care of hundreds of women and babies. In 2019, The Independent revealed dozens of babies and three mothers had died on the wards of the trust, in what was branded the largest maternity scandal to ever hit the NHS.

Some 201 babies and nine mothers could have survived if Shrewsbury and Telford NHS Hospital Trust had provided better care, an inquiry has found.

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 reasons for these failures are clear. Going forward, there can be no excuses.” 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”. “There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths. “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.

Inquiry into maternity practices at Shrewsbury and Telford hospital trust finds 201 babies could have survived with better care.

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. “In many cases, mothers and babies were left with lifelong conditions as a result of their care and treatment. “Throughout our final report we have highlighted how failures in care were repeated from one incident to the next,” she said. “We will be fully reviewing the findings of the report and feeding appropriate elements into our investigation. Javid offered reassurances that NHS staff responsible for the “serious and repeated failures” would be held to account. A total of 201 babies and nine mothers could have or would have survived if the NHS trust had provided better care, the inquiry found.

Their investigation into baby deaths and other failings in Shropshire is said to be "very much active".

Then there was the investigation into University Hospitals of Morecambe Bay NHS Trust, which uncovered a "lethal mix of failures" that led to the unnecessary deaths of 11 babies and one mother between 2004 and 2013. Even more alarming is the common thread that runs through this scandal and others. "There were so many lost opportunities," she said. "I want to make sure that we leave no stone unturned in finding the people that were responsible for this and making sure that they are held to account," he said. Among the review's conclusions were that the trust was not held to account by external bodies and the reasons for the failures included a lack of staff and ongoing training. - One woman told the review team that after her daughter's death in 2012, she was given her child and put in a room on the maternity ward where "we could hear babies crying" and "we could hear people being congratulated".

Over 20 years, errors at Shrewsbury and Telford NHS Trust led to babies being stillborn, dying after birth or being left severely brain damaged. Health ...

Then there was the investigation into University Hospitals of Morecambe Bay NHS Trust, which uncovered a "lethal mix of failures" that led to the unnecessary deaths of 11 babies and one mother between 2004 and 2013. Ms Davies said: "All we ever wanted was to understand why Kate died. Even more alarming is the common thread that runs through this scandal and others. A number of health bodies have responded to the inquiry including the Nursing and Midwifery Council (NMC), which said the report's findings were "appalling". However, she earlier said she remained "very concerned that in very recent weeks staff currently working at the trust have contacted the review team to express their concerns about maternity services at the trust in the here and now". These are all exceptional cases - there is lots of good care in the NHS. But there also seems to be a failure of the culture and systems in the NHS to spot and deal with problems early enough. The health secretary added: "I'd like to reassure MPs that a number of people who were working at the trust at the time of the incidents have been suspended or struck off from the professional register, and members of senior management have also been removed from their posts. The reason for the failures included lack of staff, lack of ongoing training, lack of effective investigations and governance and a culture of not listening to the families involved. "The report clearly shows that you were failed by a service that was there you help you and your loved ones to bring life into this world, we will make the changes that the report says are needed at both a local and national level." - for the Department of Health and Social Care (DHSC) to work with the Royal College of Obstetricians and Gynaecologists, (RCOG) and Health Education England to consider how to deliver a sustainable level of obstetric training posts, to enable trusts to deliver safe staffing It made a range of recommendations - including more than 60 for the local trust involved, 15 for the wider NHS and three for the government. - repeated failures in the quality of care at the trust between 2000 and 2019 - with mothers and babies dying or suffering major injuries as a consequence

A robust and funded maternity workforce plan for England is urgently needed to prevent serious failures of care in maternity services, such as those.

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. It is essential that families are heard, staff are able to speak up and concerns are acted upon,” she said. “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. A culture of ‘them and us’ between midwifery and obstetric staff meant midwives were often afraid to escalate concerns to consultants. And nearly a third of all babies who died within seven days of birth had significant or major concerns in their maternity care that may have contributed to their deaths. A quarter of nearly 500 cases of stillbirth had significant or major concerns in their maternity care, and could potentially not have been stillborn if managed appropriately.