Shrewsbury maternity inquiry: ‘Cruelty beyond comprehension’ as mothers blamed for babies’ deaths
Mothers were blamed for their babies’ deaths while fatal issues with care went ignored over decades, a damning report into the biggest maternity scandal in the NHS has concluded.
The review into failings at Shrewsbury and Telford Hospital Trust found that 300 babies had died or suffered brain injury as a result of poor care.
Donna Ockenden, who led the inquiry, warned that poor care was still an issue at the trust despite calling for immediate actions to be carried out on initial findings in 2020.
Systemic issues at the trust were highlighted by Donna Ockendenas as long ago as November 2019 in her interim report, revealed by The Independent. But she said maternity staff had told her they still had concerns over the level of care today.
Families said they suffered “cruelty beyond comprehension” as their concerns were not addressed and some deaths were not investigated.
Health secretary Sajid Javid told the Commons on Wednesday that in one case important clinical information had been kept on post-it notes, which were then binned by cleaners.
The investigation into 1,486 families’ cases, which began in 2017, found:
Ms Ockenden, chair of the review told The Independent said she’d had staff as recently as Tuesday reach out to say they were “frightened to speak out” and “fearful of their job.”
The chair made clear there was ongoing concerns over care at the trusts despite an initial review in 2020 calling for actions to improve.
Ms Ockenden said it was “astounding” that for more than two decades the failings had not been challenged internally by the trust and that external healthcare bodies did not hold it to account.
She made clear there were ongoing concerns over care at the trust despite an initial review in 2020 demanding improvements and also warned the failures at Shrewsbury could “potentially be replicated elsewhere” outside of maternity services.
Investigations into cases involving more than 1,486 families have revealed a total of 295 avoidable baby deaths or brain damage cases as a result of poor maternity care, including 131 stillbirths, 70 neonatal deaths and 84 cases of brain damage. Nine women were also found to have died following mistakes.
Parents failed by the trust told The Independent they suffered “inhumanity” and “cruelty beyond comprehension” as they were blamed for the deaths of their babies.
The families say they weren’t listened to and called for an independent board to scrutinise hospitals implementation of the recommendations.
Health Secretary Sajid Javid said the report was a “devastating account of bedrooms that are empty, families that are bereft and loves ones taken before their time.”
Mr Javid said the 60 actions set out by Ockenden would be accepted in full and offered reassurances that the individuals who are responsible for the “serious and repeated failures” will be held to account.
The Ockenden review was first commissioned by former health secretary Jeremy Hunt in 2017 and originally covered 23 families.
In 2019 The Independent revealed initial findings of the review had identified more than a dozen women and more than 40 babies died during childbirth.
Donna Ockenden in her final report on Wednesday said the “failures in care were repeated from one incident to the next” and babies came to harm due to “ineffective monitoring of foetal growth and a culture of reluctance to perform Caesarean sections”.
