Babies and mothers died amid major failings at a hospital trust in what is likely to be the NHS’s worst ever maternity scandal.
A report leaked to The Independent shows that a “toxic” culture stretching back 40 years was in place when babies and mothers suffered avoidable death.
Children were also left with permanent disability amid substandard care at Shrewsbury and Telford Hospital NHS Trust.
Staff at the trust routinely dismissed parents’ concerns, were unkind, got dead babies’ names wrong and, in one instance, referred to a baby who died as “it”.
No apology will be sufficient or adequate for families who lost loved ones to avoidable deaths, or whose experience of becoming a parent was blighted by poor care and avoidable harmDonna Ockenden, maternity expert
In another case, parents were not told their baby’s body had arrived back from the post-mortem examination, and it was left to decompose so badly that the family never got to say a final goodbye.
The interim update report – also seen by the PA news agency – comes from an independent inquiry ordered by the Government in July 2017.
The study warns that, even to the present day, lessons are not being learned and staff at the trust are uncommunicative with families.
The inquiry, which is being led by maternity expert Donna Ockenden, was launched by former health secretary Jeremy Hunt.
Its initial scope was to examine 23 cases but this has now grown to more than 270 covering the period 1979 to the present day.
The cases include 22 stillbirths, three deaths during pregnancy, 17 deaths of babies after birth, three deaths of mothers, 47 cases of substandard care and 51 cases of cerebral palsy or brain damage.
The interim report written by Ms Ockenden details the pain suffered by the families.
It points to:
– Babies left brain-damaged because staff failed to realise or act upon signs that labour was going wrong
– A failure to adequately monitor heartbeats during labour or assess risks during pregnancy, resulting in the deaths of some children
– Babies left brain-damaged from group B strep or meningitis that can often be treated by antibiotics
– A baby whose death from group B strep could have been prevented after its parents contacted the trust on several occasions worried about their newborn baby
– Many families “struggling” to get answers from the trust around “very serious clinical incidents” for many years and continuing to the present day
– One father whose only feedback following his daughter’s death was when he bumped into a hospital employee in Asda
– One parent reporting a “closed culture” at the trust over hospital fears of being sued
– Families who told how “the trust made mistakes with their baby’s name and on occasions referred to a deceased baby as ‘it'”
– Multiple families “where deceased babies are given the wrong names by the trust – frequently in writing”
– One family who was told they would have to leave if they did not “keep the noise down” when they were upset following the death of their baby
– One baby girl’s shawl was lost by staff after her death even though her mother had wanted to bury her in it
– The “misplaced” optimism of the regulator the Healthcare Commission (a predecessor to the Care Quality Commission) that maternity services would improve following its interjection in 2007
– Families who were advised “they were the only family”, and that “lessons would be learned”. The report said “it is clear this is not correct”
– A “long-term failure” to involve families in serious incident investigations, some of which were “overly defensive of staff”
The inquiry was launched following the efforts of Rhiannon and Richard Stanton Davies, whose daughter Kate died shortly after birth in 2009, and Kayleigh and Colin Griffiths, whose daughter Pippa died shortly after birth in 2016.
Ms Davies, from Hereford, told PA: “The narrative that lessons have been learned has to change because lessons are not being learned.
“Everything within that (the leaked report) happened to us.
“I am going to push for the police to bring a charge of corporate manslaughter against the trust.”
In the report, Ms Ockenden wrote: “No apology will be sufficient or adequate for families who lost loved ones to avoidable deaths, or whose experience of becoming a parent was blighted by poor care and avoidable harm.”
The report also criticised the trust’s slow response in sending the inquiry medical records, clinical notes and other documents.
On behalf of the trust, I apologise unreservedly to the families who have been affectedPaula Clark, Shrewsbury and Telford Hospital NHS Trust
Until now, Morecambe Bay, which saw the avoidable deaths of 11 babies and one mother at Cumbria’s Furness General Hospital between 2004 and 2013, was the worst ever maternity scandal in the history of the NHS.
Bill Kirkup, who chaired the Morecambe Bay inquiry, told The Independent the interim review made for “ghastly” reading and showed “unmistakeable parallels” with the scandal at Morecambe.
Paula Clark, interim chief executive at Shrewsbury and Telford Hospital NHS Trust, said: “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.”