The BBC reported during their Panorama programme, Maternity Scandal: Fighting for the Truth, on 23.02.22 that “babies who should have been perfectly healthy, suffered permanent injuries or died.”
The maternity unit at the Shrewsbury and Telford Hospital NHS Trust (SaTH) has been under investigation since the early 2000’s for repeated failures in maternity care at their hospitals. In March 2022, a report, on what has been named by the BBC as “one of the biggest scandals in the history of the NHS”, will be published and will investigate the circumstances that led to many baby deaths, birth injuries and injuries to mothers during labour and delivery.
In 2000, Sonia and Phil Leigh gave birth to her daughter Kathryn, at Shrewsbury Hospital, but she sadly died shortly after being delivered by emergency caesarean and experiencing difficulties breathing. At inquest, it was found that Kathryn was placed on incorrect resuscitation equipment, which was acknowledged by Shrewsbury Hospital.
In 2005, SaTH reported that it delivered 1 in 5 babies by caesarean section and stated that the “culture of our organisation is that we have low intervention rates and once that is known, we attract both midwives and obstetricians who like to practice in that way”. At that time, the NHS was working towards reducing caesarean section deliveries and increasing vaginal deliveries (sometimes called “natural births”).
In 2009, Richard Stanton and Rhiannon Davies’ daughter, Kate, was born in a midwife-led maternity unit of SaTH in Ludlow. Kate sadly died 6 hours after birth. Rhiannon Davies was concerned about lack of foetal movements in the days before birth, but there was a failure to investigate the issue after she reported it. An inquest was held into Kate’s death, which found that she should have been delivered in a hospital and the fact that she had been born in a midwife-led unit, caused, or contributed to her death. The finding resulted in a review being ordered into the maternity services in Shropshire. This was carried out by the Local Clinical Commissioning Group, who found several problems, including lack of staff and a high number of babies requiring neonatal care, but overall the conclusion was that “the maternity service was something to be proud of.”
In 2015, Furness General Hospital, part of University Hospitals of Morecambe Bay NHS Foundation Trust, was found to have made significant failures which led to the unnecessary deaths of 11 babies and 1 mother. This led to an inquiry into the Trust’s maternity services which found “a dysfunctional maternity unity… with an overemphasis on a normal birth at any cost.”
In December 2015, Tamsin Bell gave birth to her daughter Ivy at SaTH, who later died in May 2016 due to severe brain damage that she suffered after being deprived of oxygen at birth. At an inquest into Ivy’s death, it was found that midwives had mistakenly monitored the mother’s heart rate rather than Ivy’s, which led to a failure to identify when Ivy was in distress. It was also found that there was a failure to follow guidelines requiring doctors to have been alerted. The coroner ordered a Regulation 28 Report and wrote to SaTH stating that it must improve.
In 2016, Kayleigh and Colin Griffith’ daughter Pippa was born at home with the assistance of midwives from SaTH. Pippa sadly died when she was just 31 hours old from a bacterial infection, Strep B, which was not investigated, despite concerns being raised multiple times over a 24-hour period that Pippa was struggling to feed and was vomiting brown fluid. BBC Panorama reported that Pippa’s mother was later told that “nothing could have been done.” At an inquest, SaTH accepted that if Pippa had been taken to hospital for investigation, she would have received treatment and likely would have survived.
In May 2017, Donna Ockenden, Senior Midwifery Adviser to the chief executive of the Nursing and Midwifery Council, was appointed to lead a review of the maternity care provided at SaTH, which started with 23 cases of baby deaths or injuries. The review found that SaTH’s caesarean section rates were “12% higher than the national average.” Ms Ockenden found that “there are cases where an earlier recourse to a caesarean section rather than a persistence to a normal delivery may well have led to a better outcome for mother or baby or both. Low caesarean section rates were a prize” Following her review, Ms Ockenden said that “these are amongst the most serious cases that we have seen in our careers” and made a public appeal for parents who may have experienced failures in care at SaTH to come forward.
During the Ockenden Review, it was found that SaTH had developed an in-house investigation process, which was not line with the NHS investigation process and failed to identify opportunities for improvement. Calls for investigations by previous employees of the Trust, including Mr Bernie Bentick, Consultant Obstetrician and Gynaecologist, were ignored by the Care Quality Commission (CQC), an independent regulator of all health and social care services in England. Later in 2017, the CQC published an inspection report which identified that the Trust “requires improvement overall” but that “openness and transparency about safety was encouraged.” The CQC returned to Trust in 2018 for inspection and on this occasion, it found that the SaTH maternity unit was “inadequate” and it was placed into special measures.
During the BBC Panorama programme, Professor Ted Baker, Chief Inspector of Hospitals at the CQC, said that the CQC had “identified problems at the Maternity service at Shrewsbury and Telford and have subsequently taken enforcement action around that…but we are not able to drive improvement ourselves, that has to be the Trust.”
In 2018, another mother, Charlotte Harris, who was diabetic, which meant that her pregnancy was classed as high risk and she required close monitoring, raised concerns with SaTH that she had woken up in a wet bed. She was sent home without further investigations and 2 days later, she returned to hospital due to lack of foetal movements. Sadly, her baby, Jacob, died, and the Trust later admitted that if she had been monitored more closely, he could have been delivered early and would have survived.
Jo Mountfield, Vice President of the Royal College of Obstetricians and Gynaecologists (RCOG) said during the BBC’s Panorama programme that there are “reasons why maternity services are not listening to women in the way they should be…maternity services are chronically understaffed.” The RCOG’s analysis into maternity services found that in nearly three quarters of cases of baby deaths, brain injuries and still births, better care may have led to healthier outcomes. In 2020, the Office of National Statistics found that in England and Wales “around 7 in every 1,000 births ended in a still birth or neonatal death.”
In June 2020, Donna Ockenden published an interim report which stated that the number of cases being investigated at SaTH had risen from 23 to 1,862 between 2000 and 2019. The report states that there was a “failure to escalate concerns, poor monitoring of babies’ heart rates, little freedom for women to choose c-section births” and a “deeply worrying lack of kindness and compassion in the delivery of care.”
Mr Jeremy Hunt, the Chair of the Health and Social Care Select Committee, said during BBC’s Panorama that he “would not be surprised if there are pockets of these kinds of issues all over the NHS.” Reviews are currently being launched in maternity services in East Kent, Nottingham and South Wales.
The BBC reported that “the NHS has asked all NHS Trusts to stop using caesarean section rates to measure performance…they are committed to providing safe, compassionate care and has already taken significant steps to further transform safety…the CQC is carrying out inspections focussing on maternity services.” Professor Ted Baker said that in 2017, the CQC found that maternity units in 50% of NHS Trusts in England required improvement. This figure has now decreased to 41%.
In a formal statement, SaTH said that “it takes full responsibility of the failings of the standard of care within its maternity services and apologises for all the distress and hurt caused…it has made strong progress including significant investment in additional staff and training.”
Donna Ockenden’s full report will be published in March 2022 and has said that this report will be “clear and unambiguous in its findings.”
Moosa-Duke Solicitors are experienced clinical negligence solicitors with expertise in investigating birth injury claims and failures in maternity care. If you believe that you or a family member may be a victim of medical negligence, please call us for a no obligation discussion on 0116 2547456 or email us at enquiries@moosaduke.com.