Urgent and sweeping changes are needed in all English hospitals to prevent avoidable baby deaths, stillbirths and neonatal brain damage, a damning report into one of the biggest scandals in the history of the NHS has said.
It uncovers a pattern of grim failures at Shrewsbury and Telford hospitals (SaTH) that led to the deaths and harming of mothers and babies from 2000-2019. These included a lethal reluctance to conduct caesarean sections; a tendency to blame mothers for problems; a failure to handle complex cases; a lack of consultant oversight, and a “deeply worrying lack of kindness and compassion”.
The review details a series of immediate actions and “must do” recommendations for all hospital trusts to improve maternity safety “at pace”. These include formal risk assessment at every antenatal contact, twice-daily consultant-led maternity ward rounds, women and family advocates on the board of every NHS trust, and the appointment of dedicated lead midwives and obstetricians.
The independent review, by a team led by midwifery expert Donna Ockenden, found 1,862 serious incidents including hundreds of baby deaths and an unusually high number of maternal deaths, mostly between 2000 and 2019.
In June West Mercia police launched an investigation into the worst of the cases.
A clinical review of a selection of 250 of the cases prompted Ockenden to outline Thursday’s emerging findings report so that action can be taken now before the full report is completed. When completed the review is likely to be the largest in NHS history.
“We owe it to the 1,862 families who are contributing to this review to bring about rapid positive and sustainable change across the maternity services at SaTH,” says the interim report.
It calls for 27 local actions for learning and seven immediate and essential actions for all maternity services “to be implemented now and at pace”.
Other recommendations include greater oversight of maternity care by senior doctors, ringfenced funding for maternity training and the development of regional specialists in maternal medicine.
The failings identified at SaTH typify mounting concerns about safety and potentially avoidable deaths at other maternity services. In September, Prof Ted Baker, the chief inspector of hospitals, admitted to MPs that 38% of maternity services were deemed to require improvement for patient safety and some could get even worse.
Ockenden pleaded with hospitals to understand the urgent need to improve safety for mothers and babies. She said: “We implore maternity services across England to carefully consider this first report and to make ambitious plans to ensure timely implementation of these local actions for learning and immediate and essential actions takes place.”
The Ockenden review was ordered in 2017 by the then health secretary, Jeremy Hunt, after the families of two babies, Kate Stanton-Davies and Pippa Griffiths, who died under the trust’s care, raised concerns about their cases and 21 others.
Ockenden paid tribute to the parents of those babies, who she said had tried to raise serious concerns about maternity care at the trust and “who have told us they were not listened to”. She said: “Kate and Pippa’s parents have shown an unrelenting commitment in ensuring their daughters’ short lives made a difference to the safety of maternity care.”
Rhiannon Davies, who lost her daughter Kate in 2009, said: “There is a deep-seated problem in maternity, a deeper-seated problem in midwifery and a toxic issue at the heart of SaTH’s specific midwifery and obstetric services.”
She added: “Women are not aware of the risks they and their baby face during labour and birth. And whilst no one wants to feel fear and be disempowered through angst, everyone deserves openness and the accessible information to help them make an informed choice.
“In terms of midwifery, there is a culture of normal birth at any cost. This has pervaded for decades. It comes from the ideology behind current midwife training. That has to change.”
Nadine Dorries, the health minister responsible for patient safety and maternity, said: “I expect the trust to act upon the recommendations immediately, and for the wider maternity service right across the country to consider important actions they can take to improve safety for mothers, babies and families.
“This government is utterly committed to patient safety, eradicating avoidable harms and making the NHS the safest place in the world to give birth. We will work closely with NHS England and Improvement, as well as Shrewsbury and Telford hospital NHS trust to consider next steps.”
Louise Barnett, SaTH’s chief executive, said it would implement all the recommendations in full. She said: “On behalf of the whole trust, I want to say how very sorry we are for the pain and distress that has been caused to mothers and their families due to poor maternity care at our trust.
“I can assure the women and families who use our service that if they raise any concerns about their care they will be listened to and action will be taken.”
