‘Largest maternity scandal in NHS history’: Dozens of mothers and babies died on wards of hospital trust, leaked report reveals

Exclusive: Clinical failings with catastrophic consequences repeated over period of nearly 40 years, resulting in avoidable deaths, serious injuries and then further trauma subsequently inflicted on grieving families

Shaun Lintern
Health Correspondent
Tuesday 19 November 2019 14:09
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Dozens of mother and baby deaths condemned as maternity inquiry escalates to largest in NHS history

Dozens of babies and three mothers died on the wards of a single hospital trust, in what is being described as the largest maternity scandal in the history of the NHS, The Independent can today reveal.

Clinical malpractice was allowed to continue unchecked over a period of 40 years, with repeated failings by doctors, midwives and hospital bosses, according to a leaked internal report.

The investigation singles out the deaths of at least 42 babies and three mothers at Shrewsbury and Telford Hospital Trust (SATH) between 1979 and 2017.

More than 50 children also suffered permanent brain damage after being deprived of oxygen during birth, the investigation discovered, as well as identifying 47 other cases of substandard care.

A senior NHS source told The Independent: “I think you can say with absolute confidence this is the largest known maternity scandal in the UK – significantly larger than Morecambe Bay – and early findings show dozens of avoidable deaths.”

In total, more than 600 cases are now being examined, and with hundreds still to be looked at, the toll is expected to grow. The Independent has learnt deaths and injuries were still being reported to the panel up to the end of 2018.

The Morecambe Bay scandal, which saw 11 babies and one mother die avoidable deaths at Cumbria’s Furness General Hospital between 2004 and 2013, was, until now, the worst ever maternity scandal in the history of the health service.

The Shrewsbury investigation revealed repeated clinical errors were compounded by substandard follow-up investigations that failed to ensure lessons were learnt, while bereaved families were treated with “a distinct lack of kindness and respect”.

Staff referred to deceased babies as “it”, or got their names wrong, while many grieving parents were told their case was the only one of its kind.

On one occasion, a baby’s body was allowed to decompose over a period of weeks after a post-mortem examination, reaching such a point it prevented the mother seeing her child one final time before burial.

The SATH report reveals regulators were aware of problems as far back as 2007 when the Healthcare Commission, a forerunner to the Care Quality Commission, highlighted concerns about injuries to babies. However, the commission’s confidence the necessary improvements would be carried out was “misplaced”, it concludes.

The leaked report identifies:

  • A long-term lack of informed consent for mothers choosing to deliver their babies in midwifery-led units – where risks can be higher if problems occur – which “continues to the present day”
  • A long-term lack of transparency, honesty and communication with families when things go wrong. This supported a culture that was “disrespectful” to families who had been “damaged” as a result
  • Failure to recognise serious incidents. Many families who had undergone horrific experiences were told they were the only ones and lessons would be learnt. The report said: “It is clear this is not correct”
  • A long-term failure to involve families in investigations that were often poor and described as “extremely brief” and “overly defensive of staff”
  • A lack of kindness and respect to parents and families with multiple examples of deceased babies given the wrong names in writing or referred to as “it”
  • Not sharing learning, meaning “repeated mistakes that are often similar from case to case”. Failure to learn was present from the earliest case of a neonatal death in 1979 to cases occurring at the end of 2017
  • A lack of support for families who have “experienced significant loss and tragedy”
  • A long-standing culture at the trust “that is toxic to improvement effort”

Today’s revelations stem from the experiences of the Stanton-Davies family, who lost their baby daughter, Kate, at SATH’s Ludlow unit in March 2009 after midwives failed to monitor her condition, among a catalogue of other failures. It later emerged she should never even have been there in the first place, as mother Rhiannon Davies should have been flagged as a high-risk pregnancy.

Their determination over a subsequent decade-long fight to ensure lessons were learnt prompted the new inquiry.

They first had to fight just to secure an inquest for Kate, and then, once a jury inquest confirmed their daughter’s death had been avoidable, they challenged the NHS to re-examine how it had investigated the circumstances surrounding it.

The subsequent review identified systemic failings by the former head of midwifery Cathy Smith, and midwives who altered notes retrospectively.

Working with the parents of a second baby, Pippa Griffiths, who died in 2016 after staff ignored signs of a serious infection, they wrote to then-health secretary Jeremy Hunt, who ordered an independent investigation in 2017.

Initially, the scope of the probe was limited to 23 families at the trust, which delivers 4,700 babies a year, but dozens more cases, including deaths, were exposed by the Health Service Journal last year.

The review, led by midwife Donna Ockenden, was subsequently expanded by health secretary Matt Hancock, while the trust’s two hospitals – Royal Shrewsbury and the Princess Royal in Telford – were put into special measures.

Ms Davies said its findings, revealed in the leaked report, showed the trust’s chronic inability to learn from past mistakes had “condemned my daughter to death”, adding: “How has this been tolerated for so long? It is horrific.”

Bill Kirkup, who chaired the Morecambe Bay inquiry, was passed a copy of the document by The Independent. He said it made for “ghastly” reading and showed “unmistakeable parallels” with the scandal at Furness General Hospital.

He said: “I was extremely disappointed to read it. The facts in Morecambe Bay were bad enough but to see it happening somewhere else in the two years after is worse because it shows we haven’t learnt.

“Two clinical organisational failures are not two one-offs: they point to an underlying systemic problem that may be latent in other units. It is vital that we recognise why, and what we can do about it. There is good evidence that some straightforward but far reaching measures would benefit all maternity units, as well as greatly reducing the chances of another large-scale disaster like these two.”

In the report, Ms Ockenden concluded many of the cases included clinical failures of “knowledge, team-working and approach to risk” as well as a failure by hospital bosses to investigate errors, spot key risks and communicate properly with families.

She wrote: “These are real accounts about the suffering and grief experienced by individuals and families. Their experiences of maternity care should have been anticipated to be some of the most rewarding of their lives, but instead have often resulted in tragedy, that have continued to have long lasting and profound effects, to the current day.

“As a result of these families coming forward, this review is now one of the largest the NHS has ever conducted into infant and maternal morbidity and mortality in a single service.”

James Titcombe, whose son Joshua died as a result of poor care at the Morecambe Bay trust in 2008 and who was instrumental in getting cases investigated, said he felt “very sad” learning about events at Shrewsbury.

He said: “This is more evidence that the NHS needs to face up to the fact that there has been a systemic problem in maternity services.

“Yet again it has taken families to be the catalyst to get this exposed.”

In a statement Donna Ockenden said: “The document referred to in today’s coverage appears to be an internal status update as of February 2019. This was produced at the request of NHS Improvement and was not meant for publication. At the time I listened to the families involved in the maternity review who were very clear they wanted one, single, comprehensive independent report covering all known cases of potentially serious concern within maternity services at the trust. My independent review team and I are working hard to achieve this.”

Paula Clark, interim chief executive at the Shrewsbury and Telford Hospital Trust, said: “We have been working, and continue to work, with the independent review into our maternity services.

“On behalf of the trust, I apologise unreservedly to the families who have been affected. I would like to reassure all families using our maternity services that we have not been waiting for Donna Ockenden’s final report before working to improve our services. A lot has already been done to address the issues raised by previous cases.

“Our focus is to make our maternity service the safest it can be. We still have further to go but are seeing some positive outcomes from the work we have done to date.”

The Independent has contacted NHS England for comment.

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