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Interim report highlights substandard maternity care and toxic culture at Shrewsbury and Telford Hospital NHS Trust

Posted: 27/11/2019


An independent investigation, led by maternity expert Donna Ockenden, is being undertaken at Shrewsbury and Telford Hospital NHS Trust. The investigation is focused on the maternity care the trust provides and is primarily looking to establish evidence and facts about alleged poor care between 1979 and 2017.

While the inquiry is ongoing, with the final report scheduled to be published in 2020, an interim report was leaked and published by the Independent last week. The report is said to identify a catalogue of clinical errors which led to the deaths of dozens of babies and mothers. In addition 50 children have been left permanently disabled. It has now emerged that the trust could be prosecuted for corporate manslaughter as a result of repeated failures to learn lessons from previous errors which may have resulted in deaths happening unnecessarily. The scandal has been described as worse than the Morecombe Bay maternity scandal.

The interim report has also detailed a number of issues that have been experienced by affected family members and has described staff at the trust as being uncommunicative.

Specific issues that have been highlighted within the report include:

  • fetal heartbeats not being monitored adequately during labour;
  • babies being left with brain damage because staff failed to act upon signs that labour was going wrong;
  • babies being left with brain damage from group B strep or meningitis that can often be treated by antibiotics;
  • lack of communication / feedback following the loss of a baby;
  • families being treated without kindness or respect following the loss of their baby, including one family being told that they would have to leave if they did not “keep the noise down” when they were upset;
  • deceased babies being given the wrong name in letters from the trust.

Amy Milner, associate in the clinical negligence team at Penningtons Manches Cooper, who specialises in obstetric cases, comments: “The issues that have come out of this leaked report into maternity care at Shrewsbury and Telford Hospital Trust are both shocking and heart-breaking for the families involved. Unfortunately many of the failures that have been identified are not new problems. It is worrying that despite the Government investigating maternity care within the NHS generally, there continue to be chronic failures with previous mistakes going unheeded. 

“I regularly work with mothers who have experienced poor maternity care and have lost their babies either at birth or shortly afterwards, and I have seen first-hand the impact these events can have on families. It is so important when something goes wrong that they are given explanations as to what happened, and if appropriate, why there were failings in the care they received. 

“Often the most common question that bereaved parents have is “Is there something that we did wrong?” and “Could anything have been done to prevent it?” There is often a sense of guilt and feeling that they should have done more. For these reasons it is imperative that staff are communicative with families that have gone through this tragedy. If mistakes have occurred, trusts must learn from them to prevent similar errors from happening again.”


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