Words and video report by ITV News Correspondent Ben Chapman
Babies continued to die because of repeated failures to learn lessons, and mothers were often blamed for their deaths, an interim report into Britain’s largest maternity scandal has found.
A review looked at 250 cases of stillbirths, brain damage, and deaths of babies and mothers at the Shrewsbury and Telford Hospital Trust and says “urgent action” is needed to improve safety.
In all, 1,862 cases are being investigated, making it the largest review of its kind in NHS history.
A highly critical report found:
An “unacceptable” lack of kindness and compassion from some maternity staff
Families’ concerns about their care were dismissed or “not listened to at all”
Midwives failed to recognise when a pregnancy wasn’t progressing normally
Repeated failures to escalate problems to more senior staff
“Continuing errors” in monitoring babies’ heart beats
Inappropriate use of drugs, including oxytocin to speed up labour
A culture of reducing the number of caesarean births without considering if it was causing harm
The report found 13 mothers died between 2000 and 2019.
It does not say how many babies died or suffered serious injury, but between 2013 and 2016, maternity death rates were 10% higher than in comparable hospital trusts.
The report found "clear examples of failure to learn lessons and implement changes in practice". In some cases, there was no proper investigation when babies or mothers died.
It says documentation "often focused on blaming the mothers" and did not identify failings in care.
Steph Hotchkiss, whose daughter Sophiya died 32 hours after birth in 2014, said she was left waiting for 45 minutes in severe pain before she was checked by staff at the Royal Shrewsbury Hospital.
Ms Hotchkiss had a history of complications with pregnancies and had gone into labour 10 weeks early but she said she is certain if she was checked earlier, her daughter would have been born with a heartbeat and survived.
She said: "I will never ever get past the fact that had they have checked me as soon as I arrived, Sophiya would have been born with a heartbeat and that's ultimately what caused her passing - the lack of oxygen to her brain.
"It's heartbreaking, it's absolutely heartbreaking. It's torture because living with a 'what if' is horrible. It's something I'll never ever be able to get past."
She said even with the review proving what she has been saying, "it's not going to go away" she said.
"I should have a six year old here and I don't," she added tearfully.
Ms Hotchkiss described the actions of the hospital a "cop out and "insulting" and claimed staff even accused her of smoking during the pregnancy as an explanation of her baby's death.
"How dare they," she said. "I went to hospital in pain, something was wrong and I got left. And then it was like 'well, you must have been smoking' - no, I wasn't."
She added: "Clearly there was a problem but it doesn't mean it was my fault. It was really unfair for them to do that.
"I was already grieving and then I was like - did I actually do something wrong?
"I mean, I knew it wasn't obviously smoking but I was - what did I do? Did I eat something? - and that then made me poorly because I was constantly questioning myself."
Ms Hotchkiss says she's never had any official response from the hospital as to the reason why her daughter died.
Another family whose baby died said they felt "put off, fobbed off, and had obstacles put in our way”, the report said.
Lives could have been saved, the report concludes, if recommendations had been followed from previous maternity scandals, including at Morecambe Bay.
Ms Hotchkiss said she was "terrified" when she arrived at the hospital.
"Not having anybody come and tell me everything was okay or 'no it's not but this is what we're going to do', it was horrible," she said.
Among the individual stories included in the report, families complained of “rude and dismissive” staff. One mother was left screaming in pain for hours.
Bereavement care was often inadequate or non-existent.
Recalling the heartbreaking moment her daughter died, Ms Hotchkiss said: "I remember asking how can I say goodbye when I haven't even said hello?"
Rhiannon Davies, whose daughter Kate died because of failures in care in 2009, and who helped uncover 23 initial cases to be investigated, told ITV News: "I couldn’t imagine this happening to another family and yet here you are, presented with family after family after family.
"I just hope that those that have contributed to this tragedy read this report, and feel some of the pain that those families live with, feel ashamed, feel guilt and learn lessons. Please learn lessons."
She said she had felt physically sick reading the report and said the trust used "victim-blaming" as a way of distracting attention away from staff failings.
She added: "I felt very emotional… felt physically sick reading some of the family stories, the level of harm that babies and mothers have been subjected to – the lack of care, the lack of compassion, over and over again."
Describing the conduct of some staff towards grieving families identified by the report, Rhiannon added: "Victim-blaming, mother-blaming, I think, is a very convenient approach for this hospital trust – they would find any reason to cast doubt on what may have happened.
"In my own case I wanted to lie down and die to be quite frank with you – and they blamed me.
"Clearly this has happened to other families and other mothers and it’s obviously a method that they used – because it would close you down, it would make you question yourself, not them.
"I am sure in many, many cases, that’s what happened. Families were so crushed.
"The effect on me initially was hugely devastating.
"Fortunately, the post-mortem came out and we had the inquest and it was absolutely clear that Kate died as a result of a catalogue of catastrophic failings by the healthcare professionals who handled her."
She added: "There are obstetricians calling mothers lazy, women lying there screaming in agony for hours because they need an intervention and people doing nothing.
"This is the 21st century. This is not Victorian England. How did this happen? How, why did no one speak out at the hospital trust?"
The report demands "immediate and essential" action to be taken at the trust, which is rated Inadequate and is already in special measures.
These include greater consultant oversight of maternity care, ongoing risk assessment for all women, and more family involvement in serious incident investigations.
The review’s chair, Donna Ockenden, a senior midwife, also recommends improvements at all maternity units in England, including more collaboration between hospitals on safety issues.
She said: "Over the last three years, this independent review team has been listening to and working with families and the Trust in order to try and understand what happened.
"We have been listening so that we can enable the Trust and wider maternity services across England to be clear about the improvements needed.
"This will ensure that maternity services are enabled to continuously improve the safety of the care they provide to women and families."
In response to the report, Louise Barnett, Chief Executive at The Shrewsbury and Telford Hospital NHS Trust, said: “I would like to thank Donna Ockenden for this report but more importantly the families for coming forward.
"As the Chief Executive now and on behalf of the whole Trust, I want to say how very sorry we are for the pain and distress that has been caused to mothers and their families due to poor maternity care at our Trust.
"We commit to implementing all of the actions in this report and I can assure the women and families who use our service that if they raise any concerns about their care they will be listened to and action will be taken."
She urged women who are pregnant with any concerns or questions about their care to contact their midwife.
Health minister Nadine Dorries expressed her “profound sympathies” to the families affected.
Making a statement in the Commons, Ms Dorries said: "Today’s report makes clear that there were serious failings in maternity services at the Shrewsbury and Telford Hospital NHS Trust. I’d like to express my profound sympathies for what the families have gone through.
"There can be no greater pain for a parent than to lose a child and I am acutely aware that nothing I can say today will lessen the horrendous suffering that these families have been through and continue to suffer.
"However, I would like to give my thanks to all of the families who agreed to come forward and assist in this inquiry.
"I can assure them and members of this House that we are taking today’s report very seriously and that we expect the trust to act upon these recommendations immediately."
Ms Dorries continued: "The Ockenden review is an important document vividly showing the importance of patient safety. I can assure the House that we will learn the lessons that must be learned so that the tragic stories found within these pages will never be repeated again."
Jeremy Hunt, who was health secretary at the time the report was commissioned, said: "This is a tragic day for families across Shropshire, who have had it confirmed in black and white that hundreds of precious babies died needlessly."
He added: "The top priority must always be the safety of a child with any final decision taken by a mother on the basis of impartial advice.
"What is most shocking, though, is the scale and longevity of this scandal: it poses many challenging questions for the NHS and its regulatory system as well as to the trust.
“This report MUST NOT be allowed to gather dust. Yes, ministers are busy with Covid, but this sobering report must be a very high priority for Matt Hancock.
"I understand he is not delivering the statement today in parliament, understandable in a pandemic. Nonetheless I trust he will return to parliament himself at the earliest opportunity to show families that determination to address this issue goes right to the top."