More than 200 babies may have died and many others left with life-changing injuries due to repeated failures at an NHS Trust, a report has found.
Senior midwife Donna Ockenden’s review examined catastrophic failures in maternity care at the Shrewsbury and Telford NHS Trust (SaTH).
It said “failures in care were repeated from one incident to the next”.
The review examined almost 1,600 cases spanning 20 years and is thought to be largest of its kind in NHS history.
SaTH has previously said it takes “full responsibility” for the failures and offered its sincere apologies to affected families.
“We now know that this is a trust that failed to investigate, failed to learn and failed to improve,” Ms Ockenden said.
“This resulted in tragedies and life-changing incidents for so many of our families.”
The review revealed 201 babies could have survived had SaTH provided better care, related to 70 neonatal deaths and 131 cases where babies were stillborn.
There were also 29 cases where babies suffered severe brain injuries and 65 incidents of cerebral palsy.
Rhiannon Davies, whose daughter Kate died in 2009 said the numbers themselves did “not not tell the whole story” of the impact on families.
In all the cases identified by the inquiry, as well as nine mothers’ deaths, it found better care “might” or “would reasonably be expected” to have made a difference.
Ms Ockenden cited examples of ineffective monitoring of foetal growth and a culture of reluctance to perform Caesarean sections as repeated problems which “resulted in many babies dying during birth or shortly after”.
“The reasons for these failures are clear,” she said. “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.”
In all, Ms Ockenden identified 60 areas where improvements could be made at SaTH and said there could be “no excuses” going forward.
The review found an culture of not investigating mistakes, with hundreds of instances where SaTH failed to appropriately examine deaths or undertake serious incident investigations with mistakes being “inappropriately downgraded”.
Between 2011 and 2019, 40% of stillbirths and 43% of neonatal deaths did not even have an investigation. Of those cases that were examined, the Ockenden team graded the reviews as poor in almost half of stillbirths and over a third of neonatal cases.
On those occasions where cases were investigated, the trust failed to identify areas for improvement and missed opportunities to learn.
Ms Ockenden added the trust had a tendency to blame mothers for poor outcomes, and even in some cases for their own babies’ deaths.
The inquiry was first commissioned in 2017 following a campaign by two families who had lost their babies.
Richard Stanton and Rhiannon Davies’s daughter Kate died hours after her birth in March 2009, while Kayleigh and Colin Griffiths’ daughter Pippa died in 2016 from a Group B Streptococcus infection.
“I think you really must dig into the family details to understand the long-term, deep-seated pain and harm that has been meted out by such appallingly poor care at this trust,” Ms Davies said ahead of the report’s publication.
Former health secretary Jeremy Hunt, who commissioned the review after being approached by the families, said the findings were “far worse” than he could have imagined and he hoped it would be a “wake-up call”.
Responding to the findings, current Health Secretary Sajid Javid said they painted a “tragic and harrowing picture of repeated failures in care”.
“I am deeply sorry to all the families who have suffered so greatly,” he said. “We will make the changes that are needed so that no families have to go through this pain again.”
The review calls for increased funding, training and accountability across maternity services as well as improved post-natal care and care for bereaved families.
Louise Barnett, chief executive at the Shrewsbury and Telford Hospital NHS Trust said, the report was “deeply distressing”.
“We offer our wholehearted apologies for the pain and distress caused by our failings as a trust,” she said.
“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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