201 babies died in biggest ever NHS maternity scandal

Police are investigating 600 cases related to the Shrewsbury maternity scandal, Sajid Javid has revealed following a report detailing how more than 200 babies needlessly died in the NHS’s biggest ever maternity scandal.

The publication of the damning inquiry 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.  

Mr 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 families 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 (SaTH) are actively being investigated by police, Mr Javid told MPs today.

Trust 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 Kayleigh Griffiths, whose daughter Piipa also died as a result of inadequate care 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 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.  

Ms Ockenden also claimed that families were still coming forward with concerns over Shrewsbury’s maternity service last year, even as the trust was under severe pressure to improve.

‘Some of these recent families contacted us with reports they wanted to share with us,’ she said.  

‘We haven’t been able to include them fully within the review but what we have seen is that the themes within their reports seem to echo concerns we have previously seen during this review.

‘Seeing these repeated themes is a cause for grave concern.

‘It is clear that there are a number of areas of maternity care where the Shrewsbury and Telford Hospital NHS Trust still has significant learning to undertake.  

In releasing the report today Ms Ockenden praised Kate and Pippa’s families for their role in bringing poor care to light.

‘Kate’s and Pippa’s parents have shown an unrelenting commitment to ensuring their daughters’ short lives make a difference to the safety of maternity care,’ she said.

She added that the legacy of the report and its recommendations should be for a maternity service in England which is ‘appropriately funded, well-staffed, trained, motivated and compassionate and willing to learn from failings in care.’

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.’ 

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

‘This report is a devastating account of bedrooms that are empty, families that are bereft and loved ones taken before their time. We will act swiftly so that no families have to go through the same pain in the future.’

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

Of these, 66 are for Shrewsbury and Telford Hospital NHS Trust, 15 for the wider NHS three for the Department of Health.  

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 poor 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.

He also paid tribute to the families on their campaign for answers.

‘I cannot imagine how difficult it must have been for them to come forward and to tell their stories and this report is a testament to the courage and the fortitude that they have shown in the most harrowing of circumstances,’ he said. 

Some midwives have already been struck off or sanctioned by the professional regulator the Nursing and Midwifery Council (NMC).

One these was Claire Roberts, who was involved in the care of Pippa Griffiths.

Ms Roberts was struck off the NMC’s register just a few weeks ago but officially only suspended for 18-months to allow for an appeal. 

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.

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

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.’   

Julie Rowlings, whose daughter Olivia died after 23 hours of labour following a consultant’s use of forceps, said she wanted somebody from Shrewsbury and Telford Hospital NHS Trust to talk to her face to face about her case. 

‘I would like somebody from the trust to sit face to face with me, and talk to me. They’ve never done that,’ she said.  

‘They’ve apologised, via media, they’ve apologised to all the families via media, but they’ve never sat down with the families.

‘I want them to apologise face to face for what they put us through.

‘I’d like them to apologise for ignoring what we were trying to tell them at the time. It would go a long way.’

 NHS England’s chief midwifery officer Jacqueline Dunkley-Bent and Matthew Jolly, the national clinical director for maternity and women’s health, said in a joint statement: ‘The findings of this important report highlight the clear failings endured by families when they should have been protected and cared for at the most special time in their lives; our thoughts are with all those who have been put through this devastation and we are sorry for the loss and the pain they have experienced.’    

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.’

Shrewsbury and Telford Hospital NHS Trust is not alone in having its maternity services scrutinised, with reports expected from both Nottingham and East Kent.

An independent thematic review of maternity incidents, complaints and concerns is currently under way at Nottingham University Hospitals (NUH).

The review, looking at data from 2006, when the trust was formed, until mid October 2021, has been initiated for several reasons, but mainly due to families raising concerns about their cases, according to the review’s website.

It is expected to be completed by November 2022.

Meanwhile, an independent review into maternity and neonatal services at East Kent Hospitals University NHS Foundation Trust in the period since 2009 is also under way.

The review, which aims to complete its terms of reference by autumn 2022, is taking place following concerns raised about the quality and outcomes of maternity and neonatal care.

Last year East Kent Hospitals University NHS Foundation Trust was fined £733,000 over serious failures that led to the death of baby Harry Richford.

At the inquest into Harry’s death in January 2020, coroner Christopher Sutton-Mattocks listed a series of errors he found with the care given.

He gave a narrative conclusion that Harry’s death was contributed to by neglect and had been ‘wholly avoidable’. 

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 Hospital 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.

The UK’s worst baby scandal: The families left devastated after their children were left dead, disabled or with brain damage in two NHS hospitals

Some 201 babies and nine mothers could have – or would have – survived if an NHS trust had provided better care, an independent inquiry into the UK’s biggest maternity scandal has 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.

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.

Several mothers were made to have natural births despite the fact they should have been offered a Caesarean. Here, the parents tell of their traumatic experiences:

They ignored my warnings and said I was ‘low-risk’:

Kate Stanton-Davies died six hours after she was born because midwives failed to spot tell-tale signs of her deteriorating health, a report found.

Her mother Rhiannon Davies had raised fears over reduced movement in the womb, but was ignored by midwives who failed to properly monitor her pregnancy and wrongly deemed it low-risk.

Kate, who had anaemia, was born pale and floppy at Ludlow Community Hospital in Shropshire in March 2009. She was airlifted to Birmingham’s Heartlands Hospital but died.

A report published in February 2016 concluded her death was avoidable and identified a litany of failings and shoddy record-keeping at the Shrewsbury and Telford trust.

Two midwives were deemed responsible for the errors, which included changing Kate’s observation notes after her death.

Mrs Davies previously said: ‘You would think losing Kate would be the worst event in my life but the continual need to revisit the trauma of that day as we fight to get the truth means my distress is ongoing.

‘How many other baby deaths were avoidable, how many other investigations were not fit for purpose, how many other families have been betrayed, and how many other opportunities for learning have been lost?’

Midwives’ missed chances to save Pippa:

Pippa Griffiths could still be alive today had midwives realised she was suffering a deadly infection. The little girl was born at home in Shropshire in April 2016, but died just 31 hours later from a Group B Streptococcus infection.

A coroner ruled her death was avoidable and blamed a string of unforgiveable errors by midwives.

The inquest heard medical staff missed a crucial opportunity to save Pippa when her mother Kayleigh rang a midwife with concerns about her baby’s feeding.

A second chance to save Pippa’s life was missed when her mother rang hours later to report bloody mucus, a sign of a serious bacterial infection which could have been treated with urgent hospital treatment.

Pippa was born at 8.34am and a midwife was supposed to have gone to the family home for a check-up later in the afternoon.

But the inquest heard she failed to turn up. Pippa developed a purple rash later that night and eventually stopped breathing. Emergency services managed to get her breathing again, but she later died.

The trust accepted that chances to save Pippa’s life were missed. Following the conclusion of the inquest, Mrs Griffiths said: ‘We’ve fought for her and fought for the truth and ultimately she could have been saved.’

‘My girl was still born after I was left in a side room’

Katie Wilkins’ baby girl died at Shrewsbury Hospital after midwives left her in a side room for 48 hours and failed to properly monitor her.

Miss Wilkins was 15 days overdue when she arrived at the hospital to be induced in February 2013.

There were no beds available on the busy labour ward and Miss Wilkins, 24, claims she was ‘forgotten’ in the room for two days and visited by staff just a handful of times.

When a midwife did come to check on her progress they realised her baby’s heartbeat could not be found. Maddie was delivered stillborn in the early hours of the following day.

Hospital bosses later admitted the baby would have been born alive had they treated her in a more ‘timely’ manner.

Miss Wilkins said: ‘Maddie’s death was recorded as unexplained but we know why she died – because the midwives didn’t do their jobs properly.

‘I’d had a perfectly normal pregnancy and didn’t expect any problems with the birth. But I was left for hours at a time. The hospital was very busy and I felt like they simply forgot about me.

‘Giving birth to my stillborn daughter was heartbreaking. I should have been taking her home with me, but instead she had to stay at the hospital in a Moses basket. It was awful.’

Maddie was delivered stillborn in the early hours of February 21. The results of a post-mortem examination said the 6lbs 14oz baby girl’s death was unexplained.

In a letter to Miss Wilkins, Cathy Smith, head of midwifery at the hospital, apologised and admitted: ‘Had your induction occurred more timely, Maddison would likely to have been born alive.’ She added that practices at the hospital had now changed.

Miss Wilkins – who has since had a son and daughter with her partner Dave Jackson, 45, – is sceptical. She said: ‘We were told that changes would be made and women would be properly monitored, but now it seems that never happened. The hospital think they can say sorry and we should move on, but we can’t.’