“They told me it was because I must have been smoking - that was completely untrue,” Steph Hotchkiss says. “I avoided it like the plague. I couldn’t believe they were trying to blame me.”
Her daughter Sophiya died in September 2014, less than two days after being born by emergency Caesarean.
Steph had been rushed to the Royal Shrewsbury Hospital by her now-husband Rob in agony.
She was known to be a high risk, due to having suffered an abruption of her placenta in her previous pregnancy - but despite this, she says, she was left for 40 minutes before being seen by a doctor or a nurse.
That’s when they discovered it had happened again.
By the time Sophiya was eventually delivered, her heart had stopped and she had to be resuscitated - but her brain had already been starved of oxygen.
“They came in at 10.15, she was born at 10.54. So had they come in at 9.30 when I arrived or shortly after, she would have been born by the time they actually came in to check me,” Steph said.
“So she wouldn’t have… they fixed everything else but they can’t fix the brain. And it was that lack of oxygen that caused that. So had they not have had that massive delay, the last six years would have been a whole lot different for me.”
“And it’s absolutely heartbreaking. It’s torture. Because living with a ‘what if’ is horrible.
“I should have a six year old here and I don’t.”
Her story is painfully familiar - a story of her pleas for help being ignored, leading to the loss of her newborn child.
Hayley Matthews gave birth to her son Jack Burn the following year.
She says throughout her 36-hour labour, she “begged” staff to give her a Caesarean - but she was ignored, and instead pushed into trying to deliver naturally.
But Jack’s shoulder got stuck on the way out, and he too suffered hypoxia - a lack of oxygen. He was taken to intensive care, but within hours, he was gone.
Their experiences were two of the original 23 cases which first sparked former Health Secretary Jeremy Hunt to order an independent review into maternity care at the hospital, led by midwife Donna Ockenden.
That review has since ballooned, to include 1,862 cases of alleged poor care in total - including stillbirths, neonatal baby deaths, the deaths of mothers, babies born with disabilities due to poor care, and failures which led to serious ongoing injuries to mothers.
Today, the first official report from the Ockenden review has been published looking at the first 250 of those cases - and it makes for damning reading.
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
It also found that between 2013 and 2016, deaths in the maternity unit were 10% higher than in comparable hospital trusts.
And as well several ‘local actions for learning’ directed towards Shewsbury and Telford Hospital Trust itself, it has made a number of strongly-worded recommendations labelled ‘Immediate and Essential Actions’, which it says must be implemented across the country to protect women, children and families across the entire NHS.
For two families in particular, today is of particular significance.
Rhiannon Davies and Richard Stanton lost their daughter Kate in 2009, after a series of failures in her care. Seven years later, Kayleigh and Colin Griffiths lost their daughter Pippa.
Between them, they compiled the initial list of 23 cases and lobbied Mr Hunt to investigate - and have campaigned determinedly for answers, not just for them, but for all families who have suffered harm.
“We don’t see ourselves as ‘campaigners’ - we just want answers, and wouldn’t take no for an answer,” Rhiannon told ITV News.
Over the years, they too have since seen internal messages which suggested she had been to blame for Kate’s death.
“To treat a bereaved mother that way - that should never have been allowed to happen. This was proved to be an utter failing of healthcare, and for Rhiannon to be blamed for that is cruel and heartless,” Richard said.
Rhiannon added: "Blaming mothers has meant they've not learned the lessons they needed to learn.
"This hospital trust has willfully, determinedly, not learned. It’s actively chosen not to learn from death after death after death - which is why we are where we are."
Meanwhile, Kayleigh Griffiths said reading the testimony of so many others had been "like a horror story."
"All the bereaved and brain damaged children that have permanently suffered harm - and it’s just one after the other, after the other, after the other," she said.
"We had suspicions that there were issues there, but it’s just way beyond anything that I could have expected to read.”
Among the recommendations are a greater consultant oversight of the department, better and more frequent risk assessments, and collaboration between different trusts.
What's more, the report states, the voices of women and their families need to be heard at board level.
The full and final report will be published at the end of 2021.
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.”
“If you are pregnant and have any questions about your current care, please contact your midwife.”