What the first critical report said

The number of babies dying during pregnancy, labour or shortly after the birth was ten per cent higher compared with similarsized hospitals. For one measure – babies dying within 28 days of the birth – the death rate was

6 per cent higher. There was a constant fear of being blamed when things went wrong. The report highlighted dangerous shortages of midwives and doctors. The maternity department needed to fill the posts of ten midwives, three consultants, six junior doctors and 16 maternity support workers. There were on average five midwives off sick daily. There were not enough resources to safely staff the maternity unit at the Princess Royal Hospital in Telford and five midwife-led units. Cliques were identified among midwives and there was a rift between those who worked at the main maternity unit in Telford and smaller midwife-led units. Managers were routinely having to deal with ‘crises’ brought about by staffing shortages. They were constantly firefighting. The culture was defensive and not focused on the learning process. The midwives had overwhelming feelings of worry, being under constant scrutiny and being terrified of things going wrong at work. The trust hadn’t appointed a designated ‘whistleblowing champion’ contrary to national guidelines. The department also relied on overseas doctors who had not been trained up to the necessary standard.