Baby deaths probe finds ‘immediate and essential’ action is needed to improve maternity care

A bereaved father has slammed a hospital trust where 42 babies and 13 mothers died in 20 years after a report blasted a catalogue of failings at two scandal-hit sites.

Richard Stanton, who lost daughter Kate hours after she was born with anaemia in 2009, said Shrewsbury and Telford Hospital NHS Trust in Shropshire ‘should hang their heads in shame’.

His comments come after a review today found women were ‘blamed for their loss,’ and in other cases families concerns were ‘dismissed or not listened to at all’.

It also found a failure to investigate after babies’ skulls were crushed during attempts to deliver them using forceps – with one dying and another getting cerebral palsy.

Between 2000 and 2019 42 babies and 13 mothers died during or shortly after childbirth at the trust but the inquiry is now examining the cases of 1,862 families.

Former Health Secretary Jeremy Hunt said he felt ‘responsible’ as it was announced the NHS will put in a ‘surveillance,’ system to prevent a repeat of the scandal.

Among the report’s damning findings were:

  • An ‘unacceptable’ lack of kindness and compassion from some staff;
  • Midwives failed to notice when pregnancies weren’t progressing normally;
  • There were repeated failures to escalate problems to senior staff as they arose;
  • ‘Continuing errors’ in monitoring babies’ heart-rates and general ‘fetal wellbeing’;
  • Inappropriate use of drugs, including oxytocin to speed up labour; 
  • Families’ concerns about care were dismissed or ‘not listened to’ by midwives.
Richard Stanton and Rhiannon Davies helped raise awareness of the scandal, following the death of their baby, Kate (pictured with Rhiannon), in 2009. Dozens of newborns died or suffered brain damage at two hospitals run by the trust

Richard Stanton and Rhiannon Davies helped raise awareness of the scandal, following the death of their baby, Kate (pictured with Rhiannon), in 2009. Dozens of newborns died or suffered brain damage at two hospitals run by the trust

Richard Stanton and Rhiannon Davies helped raise awareness of the scandal, following the death of their baby, Kate (pictured with Rhiannon), in 2009. Dozens of newborns died or suffered brain damage at two hospitals run by the trust

Today's report has commended the couple's efforts, as Mr Stanton said hospital bosses should 'hang their heads in shame'. Pictured: Rhiannon Davies

Today's report has commended the couple's efforts, as Mr Stanton said hospital bosses should 'hang their heads in shame'. Pictured: Rhiannon Davies

Today’s report has commended the couple’s efforts, as Mr Stanton said hospital bosses should ‘hang their heads in shame’. Pictured: Rhiannon Davies

Babies whose lives should have been saved: Ella and Lola Jones

Twins Ella and Lola were starved of oxygen to the brain

Twins Ella and Lola were starved of oxygen to the brain

Twins Ella and Lola were starved of oxygen to the brain

In 2014, Kelly Jones, a mother of two, discovered she was pregnant with twin girls. 

During the pregnancy, she felt pain but despite repeatedly asking staff at the Royal Shrewsbury Hospital to assess her properly, she was ignored. 

By the time medics had eventually taken her seriously, her twin girls, Ella and Lola were stillborn. 

A letter from the Trust to Mrs Jones said that its investigation showed ‘that both babies had died from severe hypoxic ischemia (oxygen starvation to the brain) contributed to by delay in recognising deterioration in the foetal heart traces and missed opportunities for earlier delivery.’ 

The midwife came in crying, saying: ‘I’m so sorry, I’m so sorry,’ Mrs Jones said at the time. ‘My girls are gone because they couldn’t be bothered to do their jobs.’ 

Although the letter, dated June 2015, promised improvements in heart rate monitoring, two months later another baby died in similar circumstances. 

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Mr Stanton tweeted today: ‘Where they have lied, we have exposed the truth. Where they have bullied, we have been dignified.

‘When they have been in denial, we have exposed the facts. They should hang their heads in shame.’

The scandal came to light following campaigning from bereaved families, notably Mr Stanton and Rhiannon Davies – the mother of his daughter Kate.

In June police opened an investigation into failings at the two hospitals where dozens of babies died or suffered brain damage.

The ’emerging finds’ report, based on 250 of the 1,800 cases, made seven urgent recommendations for maternity wards across England.

A full report into all cases brought to the independent review will be published next year.

The review said when completed it ‘will be the largest number of clinical reviews undertaken relating to a single service, as part of an inquiry, in the history of the NHS’.

Former senior midwife Donna Ockenden’s report said ‘one of the most disappointing and deeply worrying themes’ was the ‘reported lack of kindness and compassion from some members of the maternity team at the trust’.

Ms Ockenden said: ‘Many families have suffered long-term mental health problems,’ as a result of the deaths.

She added: ‘They say their suffering has been made worse by the handling of their cases by the trust.’

The chair of the independent maternity review said the initial recommendations were ‘must dos’ and should be brought in immediately.

The review ‘identified missed opportunities to learn in order to prevent serious harm to mothers and babies’.

It added: ‘However, we are unable to comment any further on any individual family cases until the full review of all cases is completed.’

The report said it was ‘indebted’ to the efforts of parents who raised awareness of the ‘avoidable,’ deaths of their children.

They included Mr Stanton and Ms Davies, as well as Kayleigh and Colin Griffiths, whose daughter Pippa died in 2016.

Speaking to the BBC, the Griffiths said the trust ‘need to own the failure, instead of saying ‘we’re sorry,’ and putting the same ”I’m sorry” statement out and then saying ”but we do deliver all these health babies”.  That’s not acceptable’.

NHS developing early warning system to spot maternity failings 

The NHS is developing a ‘surveillance’ system that will avoid repeats of the scandal linked to the deaths of at least 42 babies and 13 mothers in Shrewsbury and Telford.

Patient care minister Nadine Dorries said it is hoped the system will bring together data and ensure it is known ‘when failings are happening quickly’.

Her remarks came after Conservative former health secretary Jeremy Hunt warned poor care linked to baby deaths at Shrewsbury and Telford Hospital NHS Trust might not be a one-off and could have happened elsewhere in the country. 

Mr Hunt, who commissioned the review, told the Commons: ‘Babies’ skulls were fractured and bones were broken in excruciatingly traumatic births that would never have happened if mothers’ wishes had been listened to.

‘This is an utterly shocking report and I think the whole House is immensely grateful to Donna Ockenden and her team for such a thorough report, and indeed to the minister for taking it so seriously – as she always does. 

Mr Hunt said the report highlighted a culture within the trust of keeping caesarean rates low, adding: ‘That needs to stop not just at Shrewsbury and Telford, but everywhere throughout the NHS.

‘The biggest mistake in interpreting this report would be to think that what happened at Shrewsbury and Telford is a one-off – it may well not be, and we mustn’t assume that it is.’

Ms Dorries said: ‘The NHS is now developing a system where we can pick up this data and know when failings are happening quickly.’

Ms Dorries also acknowledged there is not consistency across the NHS on care and delivery as she said that a ‘core curriculum’ is being developed.

She explained: ‘We are at the moment developing a core curriculum of training which will be multi-disciplinary and we hope will roll out next year.

‘It will be undertaken by both midwives and doctors, and obstetricians and everybody working in the maternity unit.’

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Ms Davies added: ‘We campaigned after Kate’s death for them to learn from Kate’s death.

‘If they had learnt, Pippa would not have died. I feel a huge weight of responsibility that we didn’t fight hard enough.’

Speaking of the lack of compassion and kindness shown by staff, the report said: ‘Many of the cases reviewed have tragic outcomes where kindness and compassion is even more essential.

‘The fact that this has (been) found to be lacking on many occasions is unacceptable and deeply concerning. 

‘Evidence for this theme was found in the women’s medical records, in documentation provided by the trust and families, in letters sent to families by the trust and from through the families’ voices heard through the interviews with the review team.

‘Inappropriate language had been used at times causing distress. There have been cases where women were blamed for their loss and this further compounded their grief.

‘There have also been cases where women and their families raised concerns about their care and were dismissed or not listened to at all.’

The review team had also found ‘inconsistent multi-professional engagement’ with the investigations into serious incidents in the trust’s maternity services.

The report stated: ‘There is evidence that when cases were reviewed the process was sometimes cursory. In some serious incident reports the findings and conclusions failed to identify the underlying failings in maternity care.

‘The review team has also seen correspondence and documentation which often focused on blaming the mothers rather than considering objectively the systems, structures and processes underpinning maternity services at the trust.’

Commenting on her initial findings, Ms Ockenden said: ‘Over the last three years, this independent review team has been listening to and working with families and the trust in order to try and understand what happened.

‘We have been listening so that we can enable the trust and wider maternity services across England to be clear about the improvements needed.

‘This will ensure that maternity services are enabled to continuously improve the safety of the care they provide to women and families.

‘Today we are explaining in this first report local actions for learning and immediate and essential actions which we believe will improve maternity care, not only at this trust but across England so that the experiences women and families have described to us are not replicated elsewhere.

Maternity minister Nadine Dorries criticised Shrewsbury and Telford Hospital Trust for 'shocking failings,' that led to the deaths of newborn babies

Maternity minister Nadine Dorries criticised Shrewsbury and Telford Hospital Trust for 'shocking failings,' that led to the deaths of newborn babies

Maternity minister Nadine Dorries criticised Shrewsbury and Telford Hospital Trust for ‘shocking failings,’ that led to the deaths of newborn babies

Seven essential actions report recommends 

  1. Safety in maternity units across England must be strengthened
  2. Maternity services must ensure that women and their families are listened to
  3. Staff who work together must train together
  4. There must be robust pathways in place for managing women with complex pregnancies
  5. Staff must ensure that women undergo a risk assessment at each contact throughout the pregnancy pathway
  6. All maternity services must appoint a dedicated Lead Midwife and Lead Obstetrician
  7. All Trusts must ensure women have ready access to accurate information to enable their informed choice of intended place of birth and mode of birth 
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‘With a focus on safety, the 27 local actions for learning and seven immediate and essential actions in this report are ‘must dos’ that need to be implemented now at pace.’

Patient safety minister Nadine Dorries announced the NHS was to develop a ‘core curriculum,’ in the care and delivery of newborns, while also announcing a surveillance scheme to prevent future scandals.

She said: ‘My heartfelt sympathies are with every family who has been affected by the shocking failings in Shrewsbury and Telford Hospital NHS Trust’s maternity services.

‘I would like to thank Donna Ockenden and her team for their hard work in producing this first report and making these vital recommendations so lessons can be learnt as soon as possible.

‘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.’

Jenson, seen with parents Kate and Andrew shortly after his birth in June 2013, died two days after birth

Jenson, seen with parents Kate and Andrew shortly after his birth in June 2013, died two days after birth

Jenson, seen with parents Kate and Andrew shortly after his birth in June 2013, died two days after birth

EXAMPLES OF ‘SHOCKING FAILINGS’ AT SCANDAL-HIT NHS TRUST

The findings of the Ockenden Review have detailed a number of ‘shocking’ examples of maternity care failings by Shrewsbury and Telford Hospital NHS Trust. Here are some of the most high-profile findings from the review:

– Compassion and kindness

One patient said staff were ‘dismissive’ and the obstetrician ‘flippant’ and ‘abrupt’ after they described the woman as ‘lazy’. Another woman was left ‘screaming for hours’ before problems that required intervention were identified. The attitude of the midwives reportedly made the situation worse.

– Place of birth: Assessment of risk

One woman who delivered in a stand-alone birth centre suffered a catastrophic haemorrhage requiring transfer to the consultant unit, where she died. The family said they were not informed of the risks of birth in a midwifery unit. Another patient who laboured at the birth centre was not adequately monitored as ‘the unit was busy’. There was a delay in transferring the mother to the labour ward and the baby was delivered in a poor condition having suffered a brain injury.

– Clinical care and competency: Management of the complex

There was a delay in treating a woman’s severe high blood pressure and, following delivery, there was a further delay in seeking senior clinical advice. She died later in another hospital.

– Escalation of concerns

One woman who was admitted with contractions and early signs of infection late in her second trimester of pregnancy was seen by a junior doctor and discharged without higher level assessment. Several hours later she was readmitted and her baby was born premature.

– Management of labour: Monitoring of fetal wellbeing, use of oxytocin

Some mothers were regularly given the drug oxytocin which increases contractions. One woman was in labour and there were fetal heart rate concerns. Despite the abnormal cardiotocograph (CTG), oxytocin use was continued throughout the labour. At the caesarean section, there was evidence that there had been an obstructed labour. The baby suffered from hypoxic brain injury and died some months after birth.

Another patient who was admitted in normal labour had CTG abnormalities in the second stage which were not recognised, it was also not recognised that the maternal heart rate was being recorded rather than the fetal heart rate. The baby was born in poor condition, developed hypoxic brain injury and died several months later. For other mothers, the medication was used where babies had already demonstrated a dangerous heart rate and long delays meant some babies were left with brain injuries such as cerebral palsy.

– Traumatic birth

One patient had repeated attempts at forceps delivery. The baby sustained multiple skull fractures and subsequently died. Another woman had repeated attempts to deliver the baby using forceps. The infant was found to have skull fractures after birth and subsequently developed cerebral palsy. There was no investigation.

– Bereavement care

A woman whose baby died after a particularly traumatic delivery was seen by the consultant afterwards. The consultant was described as having ‘no compassion or understanding of the trauma experienced’. A mother whose baby died 17 hours after birth said she and her partner were offered ‘no support’ and hospital staff were ‘lacking in compassion and actually making it so many times worse’.

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Former health secretary Mr Hunt said ‘of course’ he felt responsible for what happened during his time in charge of the department from 2012-18.

‘You are responsible for all the care that happens while you are health secretary,’ he said.

Mr Hunt told BBC Radio 4’s World at One: ‘It’s clear from this report that much more needs to happen.

‘One of them is we need to stamp out this ideology of so-called ‘normal births’ where mothers are clearly being put under pressure not to have C-sections.

‘At Shrewsbury and Telford their C-section rate was about half the national average.

‘The safety of the child should always be paramount and decisions should be taken in consultation and partnership with a mother.’

West Mercia Police has also launched its own investigation to establish if there are any grounds for criminal proceedings.

The 27 local actions for learning involve recommendations around general maternity care, maternal deaths, obstetric anaesthesia and neonatal care.

The report also found the trust had 10 chief executives since the year 2000.

Louise Barnett, the latest person to take the position Shrewsbury and Telford Hospital NHS Trust, said: ‘I would like to thank Donna Ockenden for this report but more importantly the families for coming forward.

‘As the chief executive now and 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.

‘We commit to implementing all of the actions in this report and 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.’

‘If you are pregnant and have any questions about your current care, please contact your midwife.’

In 2014, Kelly Jones, a mother of two, discovered she was pregnant with twin girls. 

During the pregnancy, she felt pain but despite repeatedly asking staff at the Royal Shrewsbury Hospital to assess her properly, she was ignored. 

By the time medics had eventually taken her seriously, her twin girls, Ella and Lola were stillborn.  

Kate and Andrew Barnett from Newtown lost their son Jenson two days after his birth in June 2013, after he suffered brain trauma during an unsuccessful forceps delivery.  

Mrs Barnett, 35, told the Daily Mail in June how consultants had to use forceps during the delivery.

But they said they ‘could not work out which way his (Jenson’s) head was to apply them, so they applied them incorrectly.

‘When they went to pull him the bed shunted back and the forceps slipped off his head. I then got rushed for an emergency caesarean section.’

Jenson’s inquest was held the following year in March 2014, where a coroner ruled that the injuries he suffered during birth were ‘avoidable’.

Babies whose lives should have been saved: Pippa Griffiths

In photographs Colin and Kayleigh Griffiths look delighted as they show off their new arrival. 

Cradled on mum’s lap, shortly after being born in a planned home birth in north Shropshire, is Pippa next to her big sister Brooke. All the family delighted. 

But a day later, on April 27, 2016, Pippa died from an infection she contracted during her birth. 

A midwife said she would return in the afternoon after the baby was born – but never turned up, the inquest was told. Pippa died at 4.09pm on April 27. 

Pippa, with parents Colin and Kayleigh and sister Brooke, died at one day old

Pippa, with parents Colin and Kayleigh and sister Brooke, died at one day old

Pippa, with parents Colin and Kayleigh and sister Brooke, died at one day old

Colin and Kayleigh were concerned about Pippa’s feeding and contacted midwives shortly after her birth, who reassured them. 

But in the early hours of the following day, Kayleigh noticed her daughter had vomited brown mucus. Later that morning, the baby’s condition worsened. She developed a purple rash and then stopped breathing. 

Emergency services managed to get her breathing again, but she later died. 

The inquest was told that the trust accepts it should have given Pippa’s mother a leaflet explaining trigger words so she could have accessed help and accepts a midwife should have returned to see her within 24 hours. It is also accepts that during a phone call, if they had asked the right questions and got the right responses, the baby would have survived at that point. 

There was also a possibly that the baby could have survived if she had gone to the hospital.

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