201 babies died in biggest ever NHS maternity scandal

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More than 200 babies needlessly died in the NHS’s biggest ever maternity scandal, according to a damning inquiry which has prompted victims to call for the police to prosecute hospital bosses.

Shrewsbury and Telford Hospital NHS Trust presided over catastrophic failings for 20 years and failed to learn from its own inadequate investigations, which led to dozens of babies being stillborn, dying shortly after birth or being left severely brain damaged due to an obsession with natural births.

The landmark probe claimed 201 babies and nine mothers would have survived if the Shropshire trust provided better care. Ninety-four children suffered avoidable brain damage. Mothers were even blamed for their own deaths and their ‘poor outcomes’.  

Donna Ockenden, the senior midwife in charge of the five-year investigation which looked at almost 1,600 incidents between 2000 and 2019, revealed families were still coming forward in 2021 to complain of safety issues with the maternity department.

She also said that staff were frightened to speak out about failings amid ‘a culture of undermining and bullying’. 

Ex-Health Secretary Jeremy Hunt today said the scale of the report was ‘beyond his darkest fears’ when he originally ordered the probe to look at just 23 cases of potential poor care.  

Sajid Javid, currently in charge of the Department of Health, called the findings of the Ockenden report ‘tragic’ and ‘harrowing’ with the poor care turning what should have been moments of joy and happiness for famalies into ‘unimaginable trauma’.   

Prime Minister Boris Johnson told the House of Commons: ‘Every woman giving birth has the right to a safe birth and my heart therefore goes out to the families for the distress and suffering they have endured.’ 

Meanwhile, Richard Stanton, whose daughter Kate Stanton-Davies died shortly after being born under the Trust’s watch in 2009, described the report as a ‘watershed moment’ for the NHS. He added: ‘I hope the police will now have sufficient evidence to present to the CPS for a prosecution.’

Around 600 cases involving poor care at Shrewsbury and Telford Hospital NHS Trust are actively being investigated  by police, Mr Javid told MPs today.

Shrewsbury and Telford Hospital NHS Trust’s chief executive Louise Barnett today apologised for the pain and affected families had endured. But another grieving parent, Kayleigh Griffiths, said the organisation’s ‘words aren’t going to be enough’. 

Mr Stanton whose daughter Kate Stanton-Davies died shortly after being born under the trust’s watch in 2009, told the Daily Mirror: ‘This is a watershed moment for maternity care across the NHS.’

‘SaTH was a horrendous case but they were not an isolated trust. You only have to look in East Kent and Nottingham where hundreds more families are coming forward to express concern about the care they received.’ 

His wife, Rhiannon Davies, gave birth in a midwife-led unit run by Shrewsbury trust which had no doctors. 

Ms Davies said she recalled ‘the midwives encouraged us to go there to ‘keep their numbers up’.’ 

Her pregnancy was wrongly classified as being low-risk and she should have given birth at a hospital where doctors could be on hand.

Kate Stanton-Davies, was born ‘pale and floppy’ and died just a few hours after she was born. 

Ms Davies had suffered complications in the last month of her pregnancy due to a rare condition which means blood leaks from the foetus and into the mother.

An independent review – commissioned by NHS England following complaints lodged by the Davies family – found the original probe into Kate’s death was ‘poor’ and had ‘multiple inaccuracies’.   

Campaigning by Kate’s mother alongside another woman whose baby died at the trust, Kayleigh Griffiths, led to then health secretary Jeremy Hunt ordering an independent inquiry in 2017. 

The Ockenden inquiry found Shrewsbury and Telford Hospital NHS Trust presided over catastrophic failings for 20 years – and did not learn from its own inadequate investigations – which led to babies being stillborn, dying shortly after birth or being left severely brain damaged.

Mothers FORCED to have natural births  

Several mothers died after failings in care, while others were forced to have natural births despite the fact they should have been offered a Caesarean. 

Some babies suffered skull fractures, broken bones or developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries.

The damning report examined cases involving 1,486 families, mostly covering 2000 to 2019, and reviewed 1,592 clinical incidents.

It found there were ‘repeated errors in care which led to injury to either mothers or their babies’.

A review of 498 stillbirths found that one in four had ‘significant or major concerns’ over the maternity care given, which, if managed appropriately, might, or would have, resulted in a different outcome.

There were also significant or major concerns in the care given to mothers in two thirds of cases where the baby had been deprived of oxygen during birth.

Furthermore, nearly a third of neonatal deaths (fatalities within the first seven days of life) had ‘significant or major concerns’ over care which might have resulted in a different outcome.

The report said staff were ‘overly confident’ in their ability to manage complex pregnancies or where abnormalities were noted in pregnancy, and there was a reluctance to involve more senior staff.

There was also a culture of ‘them and us’ between midwives and obstetricians which meant some midwives were scared to involve consultants. 

In one example of shocking care failure critical information regarding a patient was written on post-it notes which cleaners then swept into the bin. 

Mothers blamed for their OWN deaths 

The report also detailed how mothers themselves were frequently blamed for their own deaths.

It detailed an incident in 2011 where a husband was told regarding his wife’s death giving birth.

‘[it was] difficult for the midwives to listen to baby’s heart beat due to her size,’ he was told. 

In another case, this time in 2002, trust documentation into the death of a mother noted: ‘She must have been responsible for some of that because she clearly did not complain very much and tended to ignore many of her symptoms.’

The report is the largest-ever inquiry into a single service in the history of the health service and has wide-ranging implications for the maternity in the NHS. 

Ms Ockenden said: ‘Throughout our final report we have highlighted how failures in care were repeated from one incident to the next.’ 

‘In many cases, mother and babies were left with life-long conditions as a result of their care and treatment.

‘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.’

She added the inquiry highlighted the need for systematic change on a local and national level to ensure women and babies received professional and compassionate care.    

‘Going forward, there can be no excuses,’ she said. 

The trust has paid out more than £58million in clinical negligence damages and costs since 2000.

Ex Health Secretary says scale of scandal is ‘beyond his darkest fears’

Former health secretary Jeremy Hunt, who originally ordered the inquiry in 2017, said the scale of the maternity scandal at Shrewsbury hospitals was ‘beyond his darkest fears’ with initial scope of the investigation concerning just 23 cases .

Mr Hunt who now chairs the Health and Social Care Committee said it was unbelievable the Government was not doing more to help mothers and babies safe in the wake of the Ms Ockenden’s report. 

‘It beggars belief that despite this urgent need for more doctors and midwives to deliver safe maternity care, later today the Government is set to reject an amendment to the Health and Care Bill that would permanently end the ongoing crisis in workforce numbers,’ he said.  

‘Many of the recommendations made by Donna Ockenden today are described as immediate and essential actions. 

‘It is therefore imperative that the Government acts urgently to give mothers confidence that measures are in place to give them a safe birth.’ 

Sajid Javid promises appalling failings won’t happen again 

Mr Javid told MPs in the House of Commons today that: ‘This report paints a tragic and harrowing picture of repeated failures in care over two decades, which led to unimaginable trauma for so many people rather than moments of joy and happiness.’

‘For these families, their experience of maternity care was one of tragedy and distress and the effects of these failures were felt across families, communities, and generations. 

‘The cases in this report are stark and deeply upsetting.’

He added the Government will be accepting the report’s 84 recommendations in full and be working with the NHS regarding their implementation.  

Mr Javid also said that the Government has already taken steps to invest in maternity and he committed to making the changes needed to ensure ‘no families have to go through this pain again’. 

Last week, ministers announced they were investing £127million into growing the maternity workforce and improving neonatal care.  

He also outlined how a number of health professionals involved in the care of mothers and babies at the trust have now either been suspended or struck off.

Mr Javid added that the active police investigation was continuing but declined to comment on it further.   

‘There is also an active police investigation, Operation Lincoln, which is looking at around 600 cases,’ he said.

Trust apologises for ‘pain and distress’ endured by victims 

Shrewsbury and Telford Hospital NHS Trust’s chief executive Louise Barnett, who came into the post in 2019, apologised for the pain and distress caused to families by failures.

‘Today’s report is deeply distressing, and we offer our wholehearted apologies for the pain and distress caused by our failings as a trust,’ she said.

‘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.’

She added the trust had already implemented some of the changes from an earlier report from Ms Ockenden’s team and it will continue to make improvements.

Detective Chief Superintendent Damian Barratt, of West Mercia Police, said an investigation into the deaths at Shrewsbury was ongoing. 

‘We launched an investigation in 2017 to explore whether there is evidence to support a criminal case against the trust or any individuals involved and this investigation remains ongoing,’ he said. 

‘This is a highly complex and very sensitive investigation that has required us to speak to a large number of people to gather as much information as we can.

‘We are also consulting with a number of medical specialists to ensure our investigation is thorough and that the best possible investigation is completed for the families involved.

‘No arrests have been made and no charges have been brought, however we are engaging with the Crown Prosecution Service as our inquiries continue.

‘Our thoughts remain with the families affected, and we can reassure the community that when there is an update on our investigation we will share this with the families involved first and foremost, and then to the wider public.’   

One of the mothers taking legal action against Shrewsbury and Telford NHS Trust is the Reverend Charlotte Cheshire, 44, from Newport, Shropshire. Her son Adam looked unwell after his birth in 2011, but her concerns were dismissed by staff at the trust, she alleges. 

After it was finally discovered that he had Group B Strep infection, he spent almost a month in intensive care. Adam, now 11, has been left with multiple health problems. 

She said: ‘What I’m ultimately hoping is that all of the families get some answers.’

‘And then, in our individual cases, about how it’s possible for there to be such systemic failings over so many years, with seemingly either no-one noticing them, or potentially them being covered up.

‘So I’m hoping first of all for answers, but secondly, I’m hoping, as a result of Ockenden, there are genuine learnings.

‘Not the sort of, ‘oh, we’ll learn and get back to you’, but genuine learnings to improve maternity safety – primarily first of all at Shrewsbury and Telford, but secondly across the country as a whole.

‘I don’t want any other family to have to go through what we’ve gone through.’  

The Royal College of Paediatrics and Child Health (RCPCH) welcomed the report echoing statements that changes must be made to ensure no family suffers the same as the Shrewsbury victims. 

RCPCH registrar Steve Turner said: ‘As a College, our hearts go out to all the families involved, and while nothing can change the ordeal they faced, or bring back the loved ones they lost, we hope the report conveys the overwhelming need for change and improvements in care, so that no other families have to go through similar ordeals.’

He added the college will now be considering the report in full detail. 

NHS Providers deputy chief executive Saffron Cordery said the report must signal a turning point in maternity care in the health service.

‘As the report rightly highlights, one of the keys to delivering better outcomes for women and babies is developing the right culture – shifting from blame to one of learning and listening,’ she said.   

‘This would better encourage proactive approaches to safety and more open conversations, and bring a more patient centred approach to managing maternity care.’

She also highlighted how the report endorses an NHS Providers estimate that annual funding boost of between £200million and £350million is needed to address maternity staffing shortages. 

NHS bosses warn maternity staff shortage mean problems can never be fixed 

Health leaders have also warned that babies and mothers are still being put at risk in England over a shortage of midwives.

NHS and midwifery chiefs told the Guardian they fear that a growing shortage of maternity staff might mean trusts are unable to meet any new standards set out in the Ockenden report.

The number of midwives employed in the NHS in England has fallen to 26,901 according to figures published last month.

This is down from 27,272 a year ago, with the RCM warning it adds to an existing shortage of 2,000 staff.  

Royal College of Midwives (RCM) chief executive Gill Walton said: ‘I am deeply worried when senior staff are saying the cannot meet the recommendations of the Ockenden review which are vital to ensuring women and babies get the safest possible maternity care.’ 

Experts have warned the shortage of midwifery staff is being driven by a failure to attract new staff and existing midwives leaving the NHS due to being overworked.   

In her previous reports Ms Ockenden noted that Shrewsbury had been intent on keeping its Caesarean section rate low, with many women denied Caesareans or persuaded to have natural births – sometimes with catastrophic results.

But it wasn’t alone, with the culture in some other NHS trusts at the time also based around women delivering naturally and reducing the rate of Caesareans.

In 2007, the RCM, the National Childbirth Trust and the Royal College of Obstetricians and Gynaecologists, signed a ‘normal birth consensus statement’.

They said: ‘With appropriate care and support the majority of healthy women can give birth with a minimum of medical procedures…

‘Procedures used during labour which are known to increase the likelihood of medical interventions should be avoided where possible.’

A later 2015 inquiry into failings at Morecambe Bay NHS trust – where 11 babies and one mother suffered avoidable deaths – found a group of midwives’ overzealous pursuit of natural childbirth had ‘led at times to inappropriate and unsafe care’.

Two years later, in 2017, the RCM dropped its ‘normal birth’ campaign and removed advice for midwives from its website.

The RCM removed its ‘top 10 tips for a normal birth’ and said the campaign would be dropped in favour of a better births plan.

For its part, the RCOG has recently apologised on Twitter for signing up to the ‘normal birth consensus statement’ in 2007.

It said this ‘may have mistakenly given the impression that targets around childbirth could take priority over safety. This is something we acknowledge and sincerely regret’.

Shrewsbury and Telford NHS Trust serves nearly half a million people in Shropshire and consists of two hospitals, the Royal Shrewsbury and the Princess Royal in Telford, as well as a number of smaller community hospitals and maternity units.