TOTS TRAGEDY
More than 200 babies and 9 mums needlessly died in biggest maternity scandal in NHS history, damning report reveals
DOZENS of mums and babies died in two decades of medical failures at scandal-hit NHS hospitals, a damning report revealed today.
Some 201 babies and nine mothers needlessly died at Midlands hospitals in the biggest maternity scandal in NHS history.
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An inquiry by top midwife Donna Ockenden today lifted the lid on a litany of devastating errors at the Shrewsbury and Telford Hospital NHS Trust.
It found maternity units were short-staffed for years and bosses refused to take responsibility for mistakes.
Alongside the tragic deaths, 94 babies suffered life-changing brain injuries as a result of “catastrophic” care.
As she spoke about the findings this morning, Ms Ockenden started by paying tribute to the families who suffered losses or life-changing injuries.
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The former midwife hailed the fact "the voices of families are now finally being heard".
She slammed the maternity services as having "failed", adding: "This is a trust that failed to investigate, failed to learn, and failed to improve.
"This resulted in tragedies and life changing incidents for so many of our families."
The report looked at more than 1,800 complaints at the Midlands hospitals, with most from between 2000 and 2019.
It found 40 per cent of stillbirths had not been investigated by the trust, similarly with 43 per cent of neonatal deaths.
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It led staff members to come forward and paint a picture of a "clique with a culture of undermining and bullying", where concerns were ignored by bosses.
And Ms Ockenden revealed maternity staff had contacted the review team only this month over worries they still have about care on the wards.
One sent an emotional message to the parents, which the top midwife delivered, saying: "I am sorry and I know that sorry is not enough but by engaging with this review we hope that our voices will finally be acknowledged and change will happen."
The top midwife said: "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.
“Going forward, there can be no excuses, trust boards must be held accountable for the maternity care they provide.
"The trust was of the belief that it's maternity services were good - they were wrong."
She added concerns were "not unique" to the trust in her review, with an overhaul required in mum-and-baby units all over England.
Prime Minister Boris Johnson told the House of Commons this afternoon: "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."
The investigation was launched after bereaved families doggedly campaigned for a probe into the errors.
A mum's pain:
Julie Rowlings' daughter Olivia died after 23 hours of labour following a consultant's use of forceps.
She said: "If it gets people to question their care and to trust their instincts then it's worth it.
"But I can't see how this trust can ever get away with this again, because I do think families will fight them now.
"They maybe wouldn't have before, but they will now.
"It's absolutely heart-breaking, but it's only the ones that we know about.
"There are families who didn't have the strength to come forward, maybe felt too much time had passed, or felt they just couldn't open those wounds up again.
"For every family out there, every family that's come forward, this is for them.
"Justice is coming. For every baby, justice is coming.
I would like somebody from the trust to sit face to face with me, and talk to me. They've never done that.
"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."
It found families were often treated badly - echoed in women's medical records, in documents provided to the inquiry by the trust and families, and in letters sent to families by the trust.
In some cases, women were blamed for losing their babies, while others had their concerns and complaints dismissed, compounding their grief at losing a child.
Target numbers for “natural” vaginal births meant women were denied or had delayed C-sections, increasing risks, the report found.
In her interim report in December 2020, Ms Ockenden described how, in 2011, a woman was in agony but was told that it was "nothing", while staff were dismissive and made her feel "pathetic". One obstetrician was abrupt and called her "lazy".
Today she added many families have come forward as recently as last year to complain about the care they got at the trust.
Tory MP Jeremy Hunt, who in 2017 ordered the Ockenden inquiry into mother and baby deaths at Shrewsbury when he was health secretary, said the numbers were "worse" than he could have imagined at the start of the process.
He told the BBC Radio 4 Today programme that initially there were 23 instances of concern.
CARE COMPLAINT
The former health sec added: "This report, from what I've been able to glean, I haven't seen it myself, is very, very shocking and sobering reading."
He said he hopes it is "a wake-up call", adding: "I think the families have played a really extraordinary role, but we have to ask ourselves, is it morally right that we need families to have to campaign over decades to get to the truth as to why their child died, rather than the NHS itself being really hungry to learn from mistakes, to put them rights, to make sure that processes are changed so these tragedies don't happen again?"
Health Secretary Sajid Javid apologised to bereaved families when he spoke in the Commons this afternoon.
He said: "The report clearly shows that you were failed by a service that was there to help you and your loved ones bring life into this world.
“Donna Ockenden’s report paints a tragic and harrowing picture of repeated failures in care over two decades, and I am deeply sorry to all the families who have suffered so greatly.
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“Since the initial report was published in 2020 we have taken steps to invest in maternity services and grow the workforce, and we will make the changes that are needed so that no families have to go through this pain again.
“I would like to thank Donna Ockenden and her whole team for their work throughout this long and distressing inquiry, as well as all the families who came forward to tell their stories.”
The Royal College of Midwives’ (RCM) Chief Executive, Gill Walton said: “It is heartbreaking that this report only came about because of the determination of the families.
"We owe them a debt that I fear can never be repaid. What we can do - all of us who are involved in maternity services – is work together to ensure we listen, and we learn from this and ensure that women and families have trust in their care."
One of the parents who came forward is Shropshire mum Charlotte Cheshire, 44.
Her son was left with severe health problems because medics were too slow to treat a bacterial infection.
'WAKE UP CALL'
The reverend from Newport, Shropshire, says her son Adam, now 11, looked unwell after his birth in 2011 but her concerns were dismissed by staff at the trust.
When it was finally discovered that he had Group B Strep infection, he was rushed to intensive care where he stayed for almost a month.
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."
PARENTS' PAIN
Richard Stanton and Rhiannon Davies, who have campaigned for years over the poor care, lost their daughter Kate hours after her birth in March 2009.
The trust noted the death but described it as a "no harm" event, although an inquest jury later ruled Kate's death could have been avoided.
Another couple in the campaign for safer care are Kayleigh and Colin Griffiths.
Their daughter Pippa died in 2016 from a Group B Strep infection. A year later, a coroner ruled her death could have been avoided.
A criminal investigation into what happened at the trust is being carried out by West Mercia Police.
An interim report from the inquiry, published in December 2020 and covering 250 reviews, found a string of failings over two decades.
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Louise Barnett, chief executive at the Shrewsbury and Telford Hospital NHS Trust said: "Today's report is deeply distressing, and we offer our wholehearted apologies for the pain and distress caused by our failings as a trust.
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"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.
"Thanks to the hard work and commitment of my colleagues, 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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