Dozens of babies and parents died in 'worst ever' NHS maternity scandal

19 November 2019, 14:51

Dozens of babies and mothers died amid major failings at a hospital trust in what is likely to be the NHS's worst ever maternity scandal.


A leaked report shows that a "toxic" culture stretching back 40 years was in place when babies and mothers suffered avoidable death at the Shrewsbury and Telford Hospital NHS Trust.


Children were left with permanent disability amid substandard care at the trust, the report says.


Staff at the trust routinely dismissed parents' concerns, were unkind, got dead babies' names wrong and, in one instance, referred to a baby who died as "it".


In another case, parents were not told their baby's body had arrived back from the post-mortem examination, and it was left to decompose so badly that the family never got to say a final goodbye.

The interim update report, which has been obtained by The Independent, comes from an independent inquiry ordered by the Government in July 2017.


The study warns that, even to the present day, lessons are not being learned and staff at the trust are uncommunicative with families.


It also points to an inadequate review carried out by the Royal College of Obstetricians and Gynaecologists (RCOG) in 2017 and the "misplaced" optimism of the regulator in charge in 2007.


The inquiry, which is being led by maternity expert Donna Ockenden, was launched by former health secretary Jeremy Hunt.

Its initial scope was to examine 23 cases but this has now grown to more than 270 covering the period 1979 to the present day.


The cases include 22 stillbirths, three deaths during pregnancy, 17 deaths of babies after birth, three deaths of mothers, 47 cases of substandard care and 51 cases of cerebral palsy or brain damage.
The interim report written by Ms Ockenden details the pain suffered by the families.


It points to:


- Babies left brain-damaged because staff failed to realise or act upon signs that labour was going wrong.


- A failure to adequately monitor heartbeats during labour or assess risks during pregnancy, resulting in the deaths of some children.


- Babies left brain-damaged from group B strep or meningitis that can often be treated by antibiotics.


- A baby whose death from group B strep could have been prevented after its parents contacted the trust on several occasions worried about their newborn baby.


- Many families "struggling" to get answers from the trust around "very serious clinical incidents" for many years and continuing to the present day.


- One father whose only feedback following his daughter's death was when he bumped into a hospital employee in Asda.


- One parent reporting a "closed culture" at the trust over hospital fears of being sued.


- Families who told how "the trust made mistakes with their baby's name and on occasions referred to a deceased baby as 'it'".


- Multiple families "where deceased babies are given the wrong names by the trust - frequently in writing".


- One family who was told they would have to leave if they did not "keep the noise down" when they were upset following the death of their baby.


- One baby girl's shawl was lost by staff after her death even though her mother had wanted to bury her in it.


- The "misplaced" optimism of the regulator the Healthcare Commission (a predecessor to the Care Quality Commission) that maternity services would improve following its interjection in 2007.


- Families who were advised "they were the only family", and that "lessons would be learned". The report said "it is clear this is not correct".


- A "long-term failure" to involve families in serious incident investigations, some of which were "overly defensive of staff".


Beth Heath, clinical negligence solicitor at Lanyon Bowdler in Shropshire, who is acting on behalf of families affected by failures at the Shrewsbury and Telford Hospital NHS Trust, said the report was “sadly not surprising” but made for horrific reading.

She said: “We have been working on behalf of a significant number of families who have suffered bereavement and life-changing brain injuries as a result of failings at these hospitals, and we are therefore acutely aware of how this scandal has affected them, and continues to do so.

“The contents of the leaked report are sadly not surprising given that we have seen repeated failings over a substantial number of years, with little apparent learning from previous mistakes.

“We have seen action plans within investigation reports that year after year have been very similar with no real change or improvement.

“It has been clear that major failings took place which led to the deaths and severe brain injuries of babies, which could have been avoided, and it now looks like the failings go back even further than anyone feared.

“This report will inevitably cause more worry for our local community, and in particular expectant mothers, and we will continue working on behalf of local families whose lives have been shattered due to clinical errors at the Shrewsbury and Telford Hospital NHS Trust.”

One of Lanyon Bowdler’s clients, Sharon Morris, whose daughter suffered a brain injury 14 years ago, said: “I am not shocked at these findings. Every day for the last 14 years we are constantly reminded of the failure by SATH to help me give birth to healthy twins.

“I was prepared for a caesarean after baby number one, but during that time they failed to notice my baby number two was in distress because they were monitoring the wrong heartbeat.

“My daughter was starved of oxygen during this time and is now severely disabled needing 24-hour care, can't eat, can't speak, struggles to walk and has learning and behavioural issues.

“This was not something we signed up for and I would not wish it upon anyone. No amount of money can change things and all we can now hope for is that changes are made to ensure other families don't suffer like we do.

"How can we trust the NHS?”

The inquiry was launched following the efforts of Rhiannon and Richard Stanton Davies, whose daughter Kate died shortly after birth in 2009, and Kayleigh and Colin Griffiths, whose daughter Pippa died shortly after birth in 2016.


Ms Davies told The Independent the leaked report showed the trust's chronic inability to learn from past mistakes had "condemned my daughter to death", adding: "How has this been tolerated for so long? It is horrific."


In the report, Ms Ockenden wrote: "No apology will be sufficient or adequate for families who lost loved ones to avoidable deaths, or whose experience of becoming a parent was blighted by poor care and avoidable harm.
"

"Many families have described to me how they live on a daily basis with the results of that poor care."


The report also criticised the trust's slow response in sending the inquiry medical records, clinical notes and other documents.


Until now, Morecambe Bay, which saw the avoidable deaths of 11 babies and one mother at Cumbria's
 Furness General Hospital between 2004 and 2013, was the worst ever maternity scandal in the history of the NHS.


Bill Kirkup, who chaired the Morecambe Bay inquiry, told The Independent the interim review made for "ghastly" reading and showed "unmistakeable parallels" with the scandal at Morecambe.


Ms Ockenden said in a statement the report was produced at the request of NHS Improvement and was not meant for publication.


She said families want "one, single, comprehensive independent report covering all known cases of potentially serious concern within maternity services at the trust. My independent review team and I are working hard to achieve this."

Paula Clark, Interim Chief Executive at The Shrewsbury and Telford Hospital NHS Trust, said: “We have been working, and continue to work, with the independent review into our Maternity services.

 “On behalf of the Trust, I apologise unreservedly to the families who have been affected. I would like to reassure all families using our Maternity services that we have not been waiting for Donna Ockenden’s final report before working to improve our services. A lot has already been done to address the issues raised by previous cases.

 “Our focus is to make our maternity service the safest it can be. We still have further to go but are seeing some positive outcomes from the work we have done to date.”

 “We have not seen or been made aware of any interim report, and await the findings of Donna Ockenden’s report so that we can work with families, our communities and NHS England/Improvement to understand and apply all of the learning identified.”

Donna Ockenden, chair of the independent review, said: "The document referred to in today's coverage appears to be an internal status update as of February  2019. This was produced at the request of NHS Improvement and was not meant for publication.

"At the time I listened to the families involved in the maternity review who were very clear they wanted one, single, comprehensive independent report covering all known cases of potentially serious concern within maternity services at the Trust.

"My independent  review team and I  are working hard to achieve this."

Additional reporting by PA