The Largest Maternity Failing in NHS History – The Shrewsbury and Telford Hospital NHS Trust Inquiry

The Largest Maternity Failing in NHS History – The Shrewsbury and Telford Hospital NHS Trust Inquiry

How it all started

Fought for by the parents of Baby Kate Stanton Daviesand Baby Pippa Griffiths for many years, Donna Ockenden, a senior midwife andadviser, published the final report on the Inquiry into the maternity servicesat The Shrewsbury and Telford Hospital NHS Trust (‘the Trust’) today onWednesday 30 March 2022.

Allowing families to be heard

Donna Ockenden wanted to ensure that the impact ofdeath or serious health complications suffered by loved ones as a result of poormaternity care was properly investigated and that the families were providedwith a voice.

The report places a spotlight on not only the concernsabout the Shrewsbury and Telford Hospital NHS Trust but also on a number ofrecent reports of concerns in multiple other Trusts relating to the sameissues.

Facts and figures from the report

The review investigated 1,592 clinical incidents and1,486 families were involved between 2000 and 2019 and included the followingservices: antenatal, intrapartum, postnatal, obstetric anaesthesia and neonatalcare. This covered the period during pregnancy, delivery and the immediateperiod after the babies were born.

Sadly, in 12 cases of maternal death, it was concludedthat none of the mothers had received care in line with what would be expectedunder best practice.

Where children were diagnosed with cerebral palsy, itwas found that in 40% of cases there were significant or major concerns withthe care received which might, or would have, resulted in a different outcome.

In cases of hypoxic ischemic encephalopathy, where thebrain does not receive enough oxygen or blood flow for a period of time, whichoften leads to disability, it was determined that in 65.9% of cases that thelevel of care provided to the newborn babies was of significant or majorconcern.

The review also looked at 498 cases of stillbirths anddetermined that 25% of these cases might or would have resulted in a differentoutcome had the mother and baby received the appropriate care.

Failings of the Trust

In the worst maternity failing in NHS history, it isimportant to understand exactly how this happened. The report is clear thatthere were repeated errors in patient's care which led to the injuries or deathsof either the mother or their babies.

Donna Ockenden describes an overarching theme that theTrust would fail to investigate and learn from the multiple serious criticalincidents that occurred. Parents were not heard and there was a lack of transparencies and openness in relation to their complaints. Many parents felt asthough their situations were ‘pushed under the carpet’ or covered up.

There were significant or multiple delays in womenbeing admitted to labour, being assessed for emergency intervention, or beingreviewed by consultants. When involving the obstetric anaesthetists, this oftenhappened at the very last minute and meant that the anaesthetist was unable to assesspatients correctly.

Many women were also discharged inappropriately andwere later readmitted after becoming extremely unwell to have emergencyprocedures. The Trust were reluctant to refer mothers or babies to anyspecialists as they were seen to be ‘overly confident’ in their ability tomanage complex pregnancies. This was evident in the neonatal unit which operatedbeyond its designated scope.

There was a culture of fear in the Trust between themidwifery and obstetric staff which led to a lack of escalation when a patientneeded it. The culture created a lack of compassion for patients, unsafeclinical practices which were left unchallenged and unaddressed, and each time,investigatory processes were not followed which led to serious incidents notbeing reviewed or learnt from.  

Outcome of the report

The final report has set immediate and essentialactions for additional funding for maternity services across the nation. Thereport highlights the importance for continuity of care, so that women receivesafe and personalised care from the same midwifery team, with a named midwifewho takes responsibility for ensuring the needs of the woman and her baby aremet through all stages. This however has been suspended until the staffinglevels of the NHS are improved.

The Shrewsbury and Telford Hospital NHS Trust mustmake immediate and significant improvements. Incidents must be gradedappropriately and recorded. All investigations must take place by amulti-professional team and lessons must be learnt to ensure the safety ofpatients.

The safety and quality of maternity services isparamount to ensure families across England are provided with the best level ofcare now and in the future.

If you have been impacted by any of the topics above,please do get in touch with our clinical negligence team who may be able toassist you. We have a specialist team who deal with stillbirth and neonataldeaths as well as catastrophic injuries caused by negligence during theantenatal, or intrapartum, or neonatal period.

The full report can be found here.

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