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The Shrewsbury and Telford Hospital Trust maternity review: a timeline of events leading to a police investigation into maternity care

Posted: 16/07/2020


Shrewsbury and Telford Hospital NHS Trust provides care to pregnant mothers in Shropshire at the Royal Shrewbury Hospital and the Princess Royal Hospital, and delivers around 4700 babies per year. The trust is currently the focus of an investigation into care given to pregnant mothers and babies; the findings from this investigation are thought to eclipse the problems identified at the Morecambe Bay Foundation Trust. Morecambe Bay Foundation Trust was subject to an independent Government inquiry in 2015, which identified the avoidable deaths of 11 babies and one mother, and was widely thought to have revealed the most significant maternity care problems seen in an NHS trust in recent years.

The Shrewsbury and Telford Hospital Trust first came under the spotlight in 2017, when the Government launched an investigation, led by independent midwife Donna Ockenden, into concerns about the care given to 23 affected families. Seven deaths had already been identified as avoidable by the local coroner at inquests. In five out of these seven cases, there were errors in monitoring babies’ heartbeats. By 31 August 2018, at least 60 separate cases, including baby deaths, brain injuries and the deaths of at least four mothers had been identified. The most recent deaths occurred in December 2017, when a mother and two babies died in unrelated incidents.

Initially, NHS Improvement and the Department of Health and Social Care declined to widen the Ockenden review, but following representations made by the Health Service Journal, the two departments agreed to widen the scope of the investigation in August 2018.

In November 2019, the Independent newspaper reported on a leaked status update relating to the review of maternity services at the trust, bringing the issue into the wider public sphere once again. This status update showed that 42 babies and three mothers had died on the wards of a single maternity hospital over the period between 1979 and 2017, and more than 50 children suffered permanent brain damage after being deprived of oxygen during birth. The report also showed that clinical failings with catastrophic consequences were repeated over a period of nearly 40 years, resulting in serious injuries and further trauma inflicted on grieving families. At this point in the review, more than 600 cases were being examined with hundreds more to be considered.

The status update found that repeated clinical errors were compounded by sub-standard follow-up investigations, which failed to ensure lessons were learnt, while bereaved families were treated with a “distinct lack of kindness and respect”. The update reveals regulators were aware of problems as far back as 2007, when the Healthcare Commission (now the Care Quality Commission) highlighted concerns about injuries to babies. The update identified:

  • a long-term lack of informed consent for mothers choosing to deliver their babies in midwifery-led units – where risks can be higher if problems occur – which “continues to the present day”;
  • a long-term lack of transparency, honesty and communication with families. This supported a culture that was “disrespectful” to families who had been “damaged” as a result of poor maternity care;
  • failure to recognise serious incidents. Many families who had experienced poor care were told they were the only ones and that lessons would be learnt. The update stated that “it is clear this is not correct”;
  • a long-term failure to involve families in investigations that were often poor and described as “extremely brief” and “overly defensive of staff”;
  • a lack of kindness and respect towards parents and families, with multiple examples of deceased babies given the wrong names in writing or referred to as “it”;
  • not sharing learning, meaning “repeated mistakes that are often similar from case to case”. Failure to learn was present from the earliest case of a neonatal death in 1979 through to cases occurring at the end of 2017;
  • a lack of support for families who have “experienced significant loss and tragedy”; and
  • a long-standing culture at the trust “that is toxic to improvement effort”.

In March 2020, the trust confirmed that it would repay money received under the NHS Maternity Incentive Scheme. The trust had received almost £1 million in 2018 for providing good maternity care, weeks before its services were rated “inadequate”. The trust said an incorrect submission had been made and ordered an independent review. By this stage, more than 900 families had contacted the Donna Ockenden review with concerns about the care they had received.

In April 2020, the total number of families involved in the review stood at 1170, as the number of families coming forward to highlight care issues to Donna Ockenden and her team had increased. Donna Ockenden wrote to 400 of these families in April to ask them if they would like their care to be independently reviewed and for their care to form part of her report. Families who were significantly affected by the care of the team at the Shrewsbury Hospital NHS Trust were asked to get in touch with Donna Ockenden and her team by the end of May so that they could be included in the investigation report.

The independent team considering the care in the Shrewsbury hospitals now includes an anaesthetist, an infection prevention expert, an ambulance expert, two paediatricians and a physician, as well as midwives, neonatologists and obstetricians. The investigation has grown from a starting position of 23 families to nearly 1200 families.

West Mercia Police has been liaising with the Ockenden review throughout, but on 30 June 2020 made a statement confirming that a police investigation will be conducted to explore whether there is evidence to support a criminal case against either the trust or any individuals involved in the provision of care. The police are considering cases from 1 October 2003, when the trust was established, but will consider serious cases prior to that date and welcome contact from concerned families.

How does maternity care go wrong?

Mothers need close care and attention during pregnancy and labour to protect both their own and the baby’s wellbeing. There are a number of problems that can arise, and these may include:

  • failing to correctly monitor a baby’s growth during pregnancy and therefore missing opportunities to refer for growth scanning and management when a baby should have been identified as small for gestational age/low birth weight;
  • failing to respond correctly to maternal reports of reduced fetal movements (when the baby’s pattern of movement changes or reduces);
  • failing to recognise high risk pregnancies and to plan care and labour accordingly (for example by ensuring that delivery takes place in a suitable high risk location);
  • failing to monitor babies correctly during labour either by listening to the baby’s heartbeat by auscultation or on the CTG (a machine which monitors the patterns of a baby’s heartbeat);
  • failing to recognise and act quickly on medical emergencies, such as placental abruption, uterine rupture, shoulder dystocia, cord prolapse, haemorrhage or acute cord compression during delivery; and
  • failing to identify neonatal infection (such as Group B Strep) in babies following delivery, which can result in meningitis and/or sepsis.

Any of these situations can limit the oxygen supply to the baby, which in turn can cause hypoxic ischaemic encephalopathy (HIE) and damage to the brain.

What happens when care goes wrong?

When care goes wrong, there are a number of life changing consequences that can arise: these range from stillbirth and neonatal death (when a baby dies in the early period following birth) to brain injuries such as cerebral palsy, developmental delay, motor impairment, cognitive impairment and/or epilepsy.

Losing a baby at or shortly after birth is a hugely traumatic experience for any parent, and can lead to understandable mental health difficulties such as post-traumatic stress disorder, anxiety and depression, all of which impact the entire family. Parents may not be able to work due to the ongoing trauma and, for those families who are able to and choose to go on to have another child, the whole experience can be filled with anxiety and mixed emotions. In the charity sector, charities such as Sands and Cruse Bereavement Care do an excellent job of providing counselling to parents following baby loss; however, this counselling is not always specialised enough to address the trauma suffered by parents following errors in maternity care.

For babies who suffer brain injuries at birth, these injuries can be life changing and can lead to a need for ongoing support for life, which may include:

  • dedicated care;
  • specialist equipment;
  • physiotherapy;
  • adapted accommodation;
  • suitable transport;
  • specialist education provision; and
  • specialist access to hobbies and holidays.

All of this support can have a significant financial cost and this makes raising a disabled child significantly more expensive than otherwise would be the case. These needs can also make it harder for parents to continue working as they had intended, which increases the financial pressure on families.

Next steps for the families involved

The findings of Donna Ockenden’s report are set to be published by the end of 2020 and will be the subject of considerable scrutiny once they are made public.

Helen Hammond, a senior associate in the clinical negligence team at Penningtons Manches Cooper, comments; “Compensation for disabled children and their supporting families can provide a child with the resources they need to maximise their potential. Following the loss of a baby, compensation can also be claimed and is often used to fund focussed therapy to help bereaved parents move forward with their grief. Any parent or family member currently considering a legal claim may find an informal chat with a legal professional helpful in order to understand more of what is involved in the process and what it can achieve.”

A timeline of the events surrounding the review of maternity care at Shrewsbury and Telford Hospital NHS Trust can be found here.

Families who have concerns about care received at the trust may wish to contact Donna Ockenden’s team and, if appropriate, the police department managing this case.


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