The NHS needs a culture change to deliver safer care

Trusts need to ensure lessons stemming from failings are being implemented while patients and their families are being treated with respect and as a valuable source of feedback

The report describes how families were treated by the hospital (Alamy)

The avoidable deaths of babies and mothers in Shrewsbury and Telford Hospital Trust’s maternity services are heartbreaking. What makes them a scandal, however, is that the problems have been known about for so long, and yet the instinct of managers was to deflect and minimise.

The Healthcare Commission, a forerunner to the Care Quality Commission, was concerned about injuries to babies in the trust’s maternity units as long ago as 2007. It was not until Rhiannon Davies and Richard Stanton insisted on answers about the death of their baby Kate in 2009 that the Parliamentary and Health Service Ombudsman concluded in 2013 that it had been the result of serious failings in care.

Continued pressure from Davies and Stanton and other parents eventually prompted Jeremy Hunt, the health secretary, to order an independent investigation in 2017. That inquiry was widened as more cases of substandard care came to light, and The Independent has now obtained a copy of its interim findings.