‘Dismissive’ and ‘unkind’ letters were sent to bereaved families trying to shift blame for the loss of babies at Shropshire’s scandal-hit hospital trust, which often failed to investigate until faced with a formal complaint or legal action, MPs have heard.
Donna Ockenden, who is leading an independent review into the Shrewsbury & Telford Hospital Trust (SaTH), gave evidence to the government’s Health and Social Care Committee just days after releasing a damning report into the first 250 of 1,862 cases she is looking into.
She said failings had been found in multiple areas and "across all professions".
“We know that many, many families tried over many years to try to get the trust structure - and that’s midwifery, obstetrics, general management, and to executive level - to listen,” she said.
“We've seen lots of examples already in the 250 really dismissive letters, very unkind letters, and … there was also a culture of 'this is your fault' to the mother - 'if you hadn't done X then your baby may have lived’.
“[So] not only not listening but blaming mothers. Mothers and fathers will tell you they've carried that guilt for years.”
She said there was also a tendency “not to investigate” until forced to by families - either through formal complaint, or via legal action being taken.
“They didn't follow national guidance and … what we found is when they did investigate, if they did investigate, they often just hung their hat on the wrong hook, so to speak,” she said.
“They picked something which certainly wasn't the cause and got diverted, so they failed to learn.
“We noticed that until a complaint came in, or until litigation was commenced, the initial trust review simply didn't happen.
“So it's not one issue - it's not that they tried to sweep things under the carpet, it's not that they just didn't listen to families, there were multi-faceted things going on and I have to say across all professions.”
The review was triggered by 23 cases compiled by two families - Richard Stanton and Rhiannon Davies, whose daughter Kate died under the care of the trust in 2009, and Kayleigh and Colin Griffiths, whose daughter Pippa died in 2016.
Then-Health Secretary, Jeremy Hunt, ordered the review and appointed Ms Ockenden to lead it. He now chairs the Health and Social Care Committee, and was among the MPs who today heard how it was doctors who had led the way in pushing for a “normal” - ie vaginal - birth at “almost any cost”.
Ms Ockenden said her team would be looking at the issue of why SaTH had such low Caesarean section rates in their full report, due out next year.
The issue of medical staff listening to mothers and families, and allowing them to be “equal partners” in their care, was one of the key messages to take from the report, she said.
“Child birth and the arrival of a new baby should be most joyous event in a family’s life,” she added.
“It’s simply unacceptable if what we leave along the way are instead broken families and women who carry guilt on their shoulders for many many years.”
The trust has apologised to families and promised to implement the recommendations in Ms Ockenden's report.