ITV News Correspondent Ben Chapman reports on the catastrophic failings of the maternity care at Shrewsbury and Telford Hospital NHS Trust
Some 201 babies and nine mothers could have survived if an NHS trust had provided better care, an independent inquiry into maternity care in Shropshire has found.
Families of babies who died or who were left seriously disabled due to catastrophic mistakes at Shrewsbury and Telford Hospital NHS Trust have received the final report of an independent inquiry today.
The Ockenden Report published its damning findings on Wednesday, warning of implications for the whole of NHS maternity care.
In its findings, 12 cases of maternal death were considered by the review team.
It concluded that none of the mothers had received care in line with best practice at the time and in 75% of the cases the care could have been significantly improved.
The major review into the trust, led by senior midwife Donna Ockenden, has examined cases involving 1,486 families, mostly from 2000 to 2019 - making it the largest inquiry into a single service in the history of the NHS.
498 cases of stillbirth were reviewed and graded - one in four cases were found to have significant or major concerns in maternity care, which if managed appropriately, might or would have, resulted in a different outcome.
"This is a trust that failed to investigate, failed to learn and failed to improve", says midwife Donna Ockenden leading review into maternity failings at Shropshire hospitals
The review's findings published today shows Ockenden's team uncovered a string of serious failures.
failures to listen to families
failures to learn from clinical incidents
failures by multiple external bodies to act to improve maternity services at the trust over a period of two decades
This final report identifies hundreds of cases where the Trust failed to undertake serious incident investigations - with even cases of death not being examined appropriately.
The review also found that where investigations did take place they did not meet the expected standards at that time and failed to identify areas for improvement in care.
These combined failings led to missed opportunities at the trust, which is currently ranked as inadequate by regulators, the report said.
The review has been a long time coming, and the fight for answers has been led by families who lost their babies due to failures in their care.
The campaign was driven by Rhiannon Davies and Richard Stanton, who lost their daughter Kate in 2009, after a series of failures in her care, and by Kayleigh and Colin Griffiths, whose daughter, Pippa, died shortly after birth seven years later.
An earlier interim report from the inquiry, published in December 2020 and covering 250 reviews, found a string of failings over two decades.
It found there was an unwillingness by Shrewsbury and Telford Hospital NHS Trust to learn lessons from its own inadequate investigations, leading to babies being born stillborn, dying shortly after birth or being left severely brain damaged.
Several mothers also died due to apparent failings of care.
Ms Ockenden’s team of investigators had found some families were wrongly blamed when their babies died, were locked out of inquiries into what happened, and were treated without compassion and kindness.
She also noted the trust pursued a strategy of keeping Caesarean section rates low, despite the fact this led to poor care and severe consequences for some families.
In the interim report, Ms Ockenden noted that for around 20 years the Caesarean section rate at the trust was consistently 8% to 12% below the English average – something that was held up regionally and nationally as a good thing.
The review team were left with the clear impression "there was a culture" within the trust to keep Caesarean section rates low, because this was perceived as the essence of good maternity care, the study said.
Unveiling her team's latest and final report on Wednesday, Ms Ockenden, said: "Throughout our final report we have highlighted how failures in care were repeated from one incident to the next. For example, ineffective monitoring of fetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth.
"In many cases, mother and babies were left with life-long conditions as a resultof their care and treatment."
Ms Ockenden adds: "The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the Trust and a culture of not listening to the families involved. There was a tendency of the Trust to blame mothers for their poor outcomes, in some cases even for their own deaths.
"What is astounding is that for more than two decades these issues have not been challenged internally and the Trust was not held to account by external bodies.
"This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding."
She continued: “Going forward, there can be no excuses, Trust boards must be held accountable for the maternity care they provide. To do this, they must understand the complexities of maternity care and they must receive the funding they require."
The report paints a "tragic and harrowing picture" of repeated failures, the health secretary says
Sajid Javid said: "Donna Ockenden’s report paints a tragic and harrowing picture of repeated failures in care over two decades, and I am deeply sorry to all the families who have suffered so greatly.
"Since the initial report was published in 2020 we have taken steps to invest in maternity services and grow the workforce, and we will make the changes that are needed so that no families have to go through this pain again.
"I would like to thank Donna Ockenden and her whole team for their work throughout this long and distressing inquiry, as well as all the families who came forward to tell their stories.”
A criminal investigation into what happened at the trust is being carried out by West Mercia Police.
Following the Ockenden report, Louise Barnett, chief executive at Shrewsbury and Telford Hospital NHS Trust, said improvements had been made and were continuing, adding: "Today’s report is deeply distressing, and we offer our wholehearted apologies for the pain and distress caused by our failings as a trust."
"We have a duty to ensure that the care we provide is safe, effective, high quality, and delivered always with the needs and choices of women and families at its heart.
"Thanks to the hard work and commitment of my colleagues, we have delivered all of the actions we were asked to lead on following the first Ockenden report, and we owe it to those families we failed and those we care for today and in the future to continue to make improvements, so we are delivering the best possible care for the communities that we serve."
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