Shropshire maternity scandal: Families 'blamed' as investigators 'miss the point'

By Dominic Robertson | Shrewsbury | Health | Published: | Last Updated:

Staff investigating serious maternity incidents at the county's major hospitals "missed the point", according to a leaked inquiry report.

The Shropshire Star has seen a version of an interim inquiry report into maternity care at Shrewsbury & Telford Hospital NHS Trust (SaTH), drafted by inquiry head Donna Ockenden – a maternity expert appointed by the Government.

The inquiry was initially looking at 23 cases, but has expanded to consider more than 270 since it was set up in 2017.

The report details a number of "themes" in failings being investigated by the inquiry.

The approach to investigations into serious incidents is listed as one of the main concerns, with a lack of involving families in both investigations and reports recorded as one of ten themes.

It also talks of families feeling "blamed" for the death of their babies.

Never informed

The report says that many families who have spoken to the inquiry were not involved in the trust investigation into their care, and that in some cases they were never informed it was subject of a serious incident review.

According to the report the inquiry team has found incidents where the internal investigation team at the trust "'missed the point' completely especially around CTG interpretation".


CTG monitors are used to record and detect a baby's heartbeat, and issues with the practice have been listed as a factor in cases where babies died at the trust.

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The report also criticises the 'brief' nature of some serious incident reports, and says they were "overly defensive of staff".

It states: "Many of the reports that we have seen were extremely brief, failed to identify key failures of care in the monitoring and interpretation of CTGs and were overly defensive of staff.

"Many families have described to the review team how they felt they were blamed for the death of their babies and how they ‘carried’ that guilt with them for many years."

Lessons not learned

Another theme is the failure to categorize incidents as "serious" at the first point.

It also says that despite families being told lessons would be learned "it is clear this is not correct".

It states: "Many family members have told the review team they were advised ‘they were the only family,’ and that ‘lessons would be learned.’

"In our conversations with large numbers of families to date, it is clear this is not correct.

"It is therefore of the greatest importance for everyone to understand that there is no benefit to service users in assuming that each incident is unique and unprecedented. There is only risk in taking that approach."

In a statement responding to the leak earlier this week, Paula Clark, interim chief executive at SaTH, said they were already taking steps to improve their services.

She said: “I would like to reassure all families using our maternity services that we have not been waiting for Donna Ockenden’s final report before working to improve our services. A lot has already been done to address the issues raised by previous cases.

“Our focus is to make our maternity service the safest it can be. We still have further to go but are seeing some positive outcomes from the work we have done to date.”

“We have not seen or been made aware of any interim report, and await the findings of Donna Ockenden’s report so that we can work with families, our communities and NHS England/Improvement to understand and apply all of the learning identified.”

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