Hospital trust offers 'wholehearted apologies' after damning report into maternity care

A hospital trust has offered its "wholehearted apologies" after a "distressing" report was released into the Shropshire maternity scandal.

Louise Barnett, SaTH's chief executive
Louise Barnett, SaTH's chief executive

The Ockenden report found that at least 201 babies and nine mothers could have been saved if Shrewsbury and Telford Hospitals Trust had provided better care.

The damning report, led by maternity expert Donna Ockenden, examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents.

It found that leaders and midwives were determined to keep Caesarean section rates low, despite the fact this repeatedly had severe consequences.

The inquiry is the largest ever into a single service in the history of the health service and has wide-ranging implications for the maternity in the NHS.

Louise Barnett, chief executive at the Shrewsbury and Telford Hospital 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.

"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."

Areas such as safe staffing, escalation and accountability, clinical governance and robust support for families have all been included as "must dos" by maternity expert Donna Ockenden in the 234-page document.

Shrewsbury and Telford Hospital NHS Trust presided over catastrophic failings for 20 years - and did not learn from its own inadequate investigations - which led to babies being stillborn, dying shortly after birth or being left severely brain damaged.

Several mothers died after failings in care, while others were made to have natural births despite the fact they should have been offered a Caesarean.

Some babies suffered skull fractures, broken bones or developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries.

Families got to read the findings from the Ockenden Report on Wednesday morning

A review of 498 stillbirths found that one in four had "significant or major concerns" over the maternity care given, which, if managed appropriately, might, or would have, resulted in a different outcome. Some 40% of the stillbirths were never investigated by the trust.

There were also significant or major concerns over the care given to mothers in two thirds of cases where the baby had been deprived of oxygen during birth.

Furthermore, nearly a third of neonatal deaths (within the first seven days of life) had "significant or major concerns" over care which might have resulted in a different outcome.

Overall, 12 deaths of mothers were investigated, none of whom received care in line with best practice at the time. In three-quarters of these cases, care "could have been significantly improved".

The report noted that internal reviews of the deaths were poor, with some women blamed for their own deaths.

More than 200 babies and mothers could have survived with better care, the report found

It said staff were "overly confident" in their ability to manage complex pregnancies or where abnormalities were noted in pregnancy, and there was a reluctance to involve more senior staff.

There was also a culture of "them and us" between midwives and obstetricians, which meant some midwives were scared to involve consultants.

Investigators pointed to "repeated failures" to escalate concerns, delays in women being admitted to the labour ward, delays to women being assessed for emergency intervention or to be seen by consultants.

The trust, which is currently ranked inadequate, was also found to have repeatedly failed to adequately monitor babies' heart rates, with catastrophic results, alongside not using drugs properly in labour.

Shropshire solicitors Lanyon Bowdler are assisting dozens of families with legal cases against Sath, and the firm's head of clinical negligence Beth Heath said the report made for distressing reading.

“We wholeheartedly support the recommendations of the report and, on behalf of the many families we have assisted with claims of clinical negligence, can only hope this represents a turning point for maternity services at Shrewsbury and Telford hospitals,” she said.

“Unfortunately, there are still unanswered questions for a lot of families. The Ockenden Review looked at cases involving 1,486 families and 1,592 cases where there were alleged failings in maternity care, limited to the period between 1999 and 2019 - and there are numerous cases outside the review.

“The main aim of clinical negligence claims is to get answers to those questions about what went wrong. The most important thing for families who have been affected by poor standards of care is always to see that lessons have been learnt and meaningful change has led to real improvements.”

Beth added: “Following the interim report published by Donna Ockenden in December 2020, several urgent recommendations were made and there is concern that these recommendations are not being met.

“We are still seeing cases with the same issues arising.

“People need to be confident that standards are being raised in their local hospitals, and I hope this report will not be ignored, and that its recommendations will be acted upon urgently to improve the level of maternity services for patients and the medical staff.”

Shropshire, Telford and Wrekin Clinical Commissioning Group executive director or nursing and quality Zena Young, said: “We deeply regret the horrific experiences these families went through and that we failed to provide the care they deserved.

“As a CCG, we are committed to offering the best health service to the people of Shropshire. We have improved the way we hear the experiences of women and families using maternity service and have also invested in funding for the Shrewsbury and Telford Hospital NHS Trust to support increases in maternity staffing levels, which now match nationally recommended staffing levels.

“We will work with our partners across the health and care system to ensure that further improvements are made in light of this report, and will continue to take all actions necessary to ensure women who use our maternity services receive the best care.”

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