Shropshire Star

Shropshire baby scandal: Inquiry reveals 27 actions needed to improve safety of county's maternity services

Essential actions to improve maternity services at Shropshire's major hospitals have today been revealed by the review looking into baby deaths and alleged failings in care.

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Donna Ockenden who is leading the review

The Ockenden inquiry is looking into more than 1,800 cases involving Shrewsbury and Telford Hospital NHS Trust (SaTH) – a number which has grown from 23 since 2017.

Its initial findings, published today, say that 27 actions need to be 'implemented at pace' by the trust which runs Royal Shrewsbury Hospital and Princess Royal Hospital in Telford.

To improve the safety of services, it recommends greater consultant oversight of maternity care and appointing lead obstetricians and midwives with expertise in fetal monitoring and bereavement care to 'lead on significant improvements'.

Rhiannon and Richard Stanton Davies

Other recommendations include ongoing risk assessment for all women and greater involvement from obstetric anaesthetists when women have complex pregnancies or become ill.

In addition, a further seven 'immediate and essential actions' have been made which not only apply to SaTH, but also maternity services across England.

One states that trusts must work together to investigate serious incidents and ensure learning is shared regionally in a timely manner.

Others focus on staff training, risk assessing women at every antenatal contact and the development of regional maternal medicine specialist centres.

In addition seven “immediate and essential actions” are needed across England to improve maternity services, says today's report.

The initial findings follow the review of 250 cases dating from 2000 to 2018, including the original 23.

Royal Shrewsbury Hospital

Donna Ockenden, chair of the review, said: “Today we are explaining in this first report local actions for learning and immediate and essential actions which we believe will improve maternity care, not only at this trust but across England so that the experiences women and families have described to us are not replicated elsewhere.

Watch: Donna Ockenden makes short statement coinciding with the publication of report

“With a focus on safety, the 27 local actions for learning and seven immediate and essential actions in this report are ‘must do’s’ that need to be implemented now at pace.”

She thanked the families at the centre of the inquiry, adding: "This first review and all of our work that follows owes its origins to Kate Stanton Davies and her parents Richard and Rhiannon and to Pippa Griffiths and her parents Kayleigh and Colin.

"Kate and Pippa’s parents have shown an unrelenting commitment in ensuring their daughter’s short lives made a difference to the safety of maternity care.”

Princess Royal Hospital, Telford

Ms Ockenden also acknowledged the efforts of the trust over the last year to support the review and said she was confident the first report would "impact positively on the maternity care provision for women in Shropshire".

She said: "What is very clear from these reviews and conversations is that for far too long women and families who have accessed maternity care at SaTH have been denied the opportunity to voice their concerns about the quality of care they have received.

"Many have experienced life changing events which has caused untold pain and distress, including sadly the deaths of mothers and babies; babies who have suffered lifelong health complications as a result of brain damage at or around the time of birth; whole families including mothers, fathers, brothers, sisters and grandparents who have been left utterly bereft.

"Many families have suffered with long-term mental health problems because of their experience of maternity care at the trust and families have expressed their suffering has been made worse as a result of the handling of these incidents by the trust."

Following its launch by then Health Secretary Jeremy Hunt in 2017, the number of cases being considered has risen from 23 to 1,862, with the majority of incidents occurring between the years 2000 to 2019.

The full and long-awaited report by the inquiry team is expected next year.

Louise Barnett, chief executive of The Shrewsbury and Telford Hospital NHS Trust

Ms Ockenden said the first report was 'by no means the end of the journey'.

She said the independent review will continue working with NHS England and Improvement, the Department of Health and Social Care and the trust as it continues with its improvement plan to ensure these changes are being actioned.

She said the team would also be examining the trust's governance structures and decision making processes, as well as considering the views of staff.

In response to the report, chief executive of SaTH Louise Barnett said: "I would like to thank Donna Ockenden for this report but more importantly the families for coming forward.

“As the chief executive now and on behalf of the whole trust, I want to say how very sorry we are for the pain and distress that has been caused to mothers and their families due to poor maternity care at our trust.

“We commit to implementing all of the actions in this report and I can assure the women and families who use our service that if they raise any concerns about their care they will be listened to and action will be taken.

“If you are pregnant and have any questions about your current care, please contact your midwife.”


Minister for Patient Safety and Maternity Nadine Dorries said: “My heartfelt sympathies are with every family who has been affected by the shocking failings in Shrewsbury and Telford Hospital NHS Trust’s maternity services.

“I would like to thank Donna Ockenden and her team for their hard work in producing this first report and making these vital recommendations so lessons can be learnt as soon as possible.

“I expect the Trust to act upon the recommendations immediately, and for the wider maternity service right across the country to consider important actions they can take to improve safety for mothers, babies and families.

“This Government is utterly committed to patient safety, eradicating avoidable harms and making the NHS the safest place in the world to give birth. We will work closely with NHS England and Improvement, as well as Shrewsbury and Telford Hospital NHS Trust to consider next steps.”

Former Health Secretary Jeremy Hunt tweeted: ~This is a tragic day for families across Shropshire, who’ve had it confirmed in black & white that hundreds of babies died needlessly. There’s nothing more cruel in life than losing a child,but to do so because of mistakes that were covered up makes things infinitely more painful.

"There are lessons that need to be learned immediately: no one should ever be pressurised to have a 'normal birth' in order to keep C-section rates low. The top priority must always be the safety of a child with any final decision taken by a mother on the basis of impartial advice."

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