Those are the words of the former health secretary Jeremy Hunt on the publication of the interim Ockenden Report which is a vindication of those bereaved parents who have striven tirelessly for the truth to be told about the county’s baby deaths scandal.
The review is a devastating indictment of maternity services at the Shrewsbury and Telford Hospital NHS Trust. But what many people will find most shocking is how the mothers were treated.
The investigation found letters and records which often focused on blaming the mothers rather than considering whether the trust’s systems were at fault. Then there was the attitude of some staff.
The report states: “One of the most disappointing and deeply worrying themes that has emerged is the reported lack of kindness and compassion from some members of the maternity team.”
So the faults were not just with decision-making, procedures, techniques, and training, but with the most fundamental quality to be expected in an organisation dedicated to care – human compassion and empathy.
There is no hiding place for the trust. This was not a problem with just a few individuals, because the width and breadth of what went wrong points to institutional failure, lack of oversight, and an inability to countenance, confront, or even investigate its mistakes.
The tragic consequence of that was that there was no assiduous drive to put things right. On the contrary, there was denial that anything was wrong in the first place. Mothers continued to have traumatic birth experiences.
This is a report that the whole NHS must take note of. To trot out the old cliche, lessons will be learned. This initial review has identified seven “immediate and essential actions” for all maternity services across England.
But that’s too late to spare the pain of so many families.