The chief executive of the trust admitted to ITV News Central's Charlotte Cross that it had "failed" communities in this special report
The boss of a scandal-hit maternity trust has admitted "we let everyone down" as it is revealed around half of "essential" and urgent improvements to care have been fulfilled.
Louise Barnett's comments come almost a year since a major independent review into maternity care in Shropshire found serious, repeated mistakes in care led to hundreds of deaths and injuries to mothers and babies.
In the 10 months since the review published its scathing final report, ITV News Central has made numerous requests for interviews with the Trust leadership, to see how much progress has been made.
Finally, we authored a formal letter - co-signed by our colleagues at the BBC and the Shropshire Star - requesting they honour their commitment to a more open, honest and transparent approach.
And at last, they agreed.
“For us, the most important thing was to really thoroughly listen to the accounts that were provided by the families,” said Ms Barnett, who took over as chief executive in February 2020.
“It was really important that we understand what this report was saying.
"And that was absolutely critical because we needed to understand it to then face into the actions that we needed to take and to bring about the improvements.”
What is the Shropshire maternity scandal?
The scandal dates back to 2009 and centres on the Shrewsbury and Telford NHS Trust hospital, focusing on medical practices at the Royal Shrewsbury Hospital and Princess Royal Hospital in Telford.
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.
These two families were instrumental in lobbying ministers to look at the standard of care being offered by the Trust.
What is the Ockenden review?
The Ockenden review was launched by then-Health Secretary Jeremy Hunt in 2017 on the basis of 23 deaths at the Shrewsbury and Telford NHS Trust.
Since then, it has ballooned to look at evidence from 1,486 families, making it one of the biggest health scandals in NHS history.
The inquiry looks at cases of death or harm between 1998 and 2017.
This includes stillbirths, neonatal baby deaths, the deaths of mothers, babies born with disabilities due to alleged poor care, and alleged failures which led to serious ongoing injuries to mothers.
In total, between the final report and 2020’s interim publication, there were 210 recommendations for the Trust to put into place to tackle the chronic failings.
Many were labelled “immediate” and “essential” by the report’s author, Donna Ockenden - but almost a year on, the Trust has completed little more than half.
To date, they have:
"For me, I think we've made really good progress," Ms Barnett insisted.
"But we want to complete everything in the report, so I think I won't be happy until we've done that - and then further continuous improvement beyond there.
"I’m really proud of the teams and the work they've done, and I think it's been really important to make progress in a way that we can feel confident is changing things on the ground for women in our communities and making a difference for them."
One of the biggest issues highlighted has been maintaining safe levels of staffing.
Director of Midwifery, Annemarie Lawrence, started at the Trust in March last year - at which point, staffing levels were at just 42%, well short of the 85% minimum safe level.
But now, after a major recruitment drive and hiring 30 newly-qualified apprentices, as of January this year they had managed to reach 86%.
There is also a daily management huddle to discuss staffing, offering up to 200% pay incentives for the Trust’s own bank staff - they never, I’m told, use agency - to cover shifts at risk of falling below the minimum level.
There is also a team of on-call community midwives on hand, in case of unexpected sickness or a rise in patient numbers.
Director of Nursing, Hayley Flavell, said the Trust had adopted a policy of "over-recruiting", to ensure staffing levels remain safe even when members of the team are sick, or on maternity leave themselves.
“We do have some further work to do to make to maintain those levels,” she said.
“We have international recruitment happening with our midwives, which I'm really excited about as it’s been very successful in the nursing part of the organisation.
“We've got the midwifery apprenticeship route as well. So there have been some challenges, definitely, but we are in a very healthy position at the moment.”
Other improvements include having a consultant on-site 24/7 - it’s no longer just a weekday role - as well as managers on-call 24/7.
New patient choices forms are put on the wall in delivery suites to ensure mothers and families are being listened to, risk assessments are carried out at every contact with expectant mothers, and they say they identify risk factors daily on a board in the handover room, to make sure all staff are aware.
But there is still concerning data coming from the Trust.
A clear upwards trend in the number of "Patient Safety Incidents" has been reported, with a 2022 high of 1,940 incidents in October alone.
Eight of these were classed as "Serious Incidents", including one in maternity; in September, there were 15 Serious Incidents out of 1,687, including four in the Women and Children’s Centre.
“This is clearly going in the wrong direction - what’s going wrong?” ITV News Central asked.
“What the incidents are showing us is there is a culture of reporting which I think is a really positive culture of reporting,” Ms Flavell said.
“We also need to address each of those incidents, which we do as an organisation. And again, it is about openness, honesty and transparency. Hence that's why they go to a public board.”
They say they believe they are on the right track to move forward and begin rebuilding the Trust’s shattered reputation within the communities of Shropshire.
But for many, the impact of the care they received will be with them forever.
Charlotte Cheshire’s son Adam will turn 12 in March.
They have spent more than a decade learning how to cope with his physical and learning disabilities - disabilities linked to complications suffered during, and shortly after, his birth.
Finally, after years of fighting, the Trust has now admitted to 80% liability in his case and agreed to a compensation package providing care for Adam, for the rest of his life.
“I feel as though I can finally stop fighting, and just be Adam’s mother,” Charlotte said.
“On the train home from the High Court, there was a moment when I had a deep, distinctive thought pop into my head: ‘It doesn’t matter if I die now’.
“Now that may sound very, very morbid, but it didn’t feel morbid to me in the moment.
“One of my biggest fears had been not just managing his care now, for me, but what happens if I die? And that - having that thought in the moment, ‘it doesn’t matter if I die now’, it just felt like a release. I don’t have to worry.”
For Hazel Harwood, the pain of her loss is still fresh.
Her daughter Mia was stillborn just days after the Ockenden Report was published - and in September, a Healthcare Safety Investigation Branch investigation found that had her pre-eclampsia been better managed, that outcome may have been different.
She is now undergoing counselling, including for post-traumatic stress disorder.
She says she can’t go near the hospital without suffering a panic attack.
“The smallest smells - I’ll smell something and I’ll be back in that hospital room,” she said.
“They failed my daughter. To know that my daughter died there - I just can’t go near it. I went there for appointments, and in their triage, they should have picked things up and they didn’t.
“So I just don’t trust that hospital to care for people the way that they should.”
Ms Barnett said she could not comment on individual cases.
“But what I would say is that the Ockenden Report set out a series of areas to focus on, and there is a whole range of actions that we're taking,” she said.
“We want to ensure that every contact and the risk assessment is done for women so that we are clear about the care that needs to be provided and of course, the nature of that may change depending on and on that going through the pregnancy.
“I think also the training. So ensuring that we've got really good training in place, whether that's about foetal monitoring and other things, like pre-eclampsia and all the different aspects really of maternity care.
"And we also do emergency skills drills as well. So one of the actions is about people that work together, the need to train together.
“And I think that's really important. So going through all the scenarios so that people feel equipped with the skills that they need going forward.
“I think, sadly, when things do happen, then we need to make sure that we really understand what the situation is.
"And I think investigating thoroughly, involving the family in that, involving that external bodies - whether it's HSIB or other experts - to ensure that we really understand the nature of that care.”
And of course, while the Trust battles to improve, a police investigation into the crisis in maternity care at the Trust is still ongoing.