Mums and babies died after failures
SOME 201 babies and nine mothers could have – or would have – survived if an NHS trust had provided better care, an independent inquiry into the UK’S biggest maternity scandal has found.
Shrewsbury and Telford Hospital NHS Trust presided over catastrophic failings for 20 years – and did not learn from its own inadequate investigations – which led to babies being stillborn, dying shortly after birth or being left severely brain damaged.
Some babies suffered skull fractures, broken bones or developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries.
Several mothers were made to have natural births despite the fact they should have been offered a Caesarean.
Prime Minister Boris Johnson told the House of Commons: “Every woman giving birth has the right to a safe birth and my heart therefore goes out to the families for the distress and suffering they have endured.”
Health Secretary Sajid Javid apologised to families and said the Government accepts the report recommendations in full.
He said some members of staff involved at the time have been suspended or struck off, while members of senior management “have been removed from their posts”.
The damning report, led by maternity expert Donna Ockenden, examined cases involving 1,486 families, mostly from 2000 to 2019, and reviewed 1,592 clinical incidents.
A review of 498 stillbirths found one in four had “significant or major concerns” over the maternity care given, which, if managed appropriately, might, or would have, resulted in a different outcome. Some 40% of these stillbirths were never investigated by the trust.
There were also “significant or major” concerns over the care given to mothers in two-thirds of cases where the baby had been deprived of oxygen during birth.
Overall, there were also 29 recorded cases where babies suffered severe brain injuries and 65 cases of cerebral palsy. Furthermore, nearly a third of neonatal deaths had “significant or major concerns” over care. Yet the trust had only looked at 43% of these.
Overall, 12 deaths of mothers were investigated, none of whom received care in line with best practice at the time. In three-quarters of these cases, care “could have been significantly improved”.
Some women were blamed for their own deaths, the report found, while incidents that should have triggered a serious incident investigation were “inappropriately downgraded” by the trust to its own series of “high risk” case reviews, which were “apparently to avoid external scrutiny”.
Ms Ockenden’s report said this “meant that the true scale of serious incidents within maternity services at the trust went unknown over a long period of time”. But she added there were still “persistent failings in incident investigations as late as 2018-2019”.