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

A bereaved father has slammed a Telford hospital trust where 42 babies and 13 mothers died in 20 years – as a scathing report into the maternity scandal blasts a catalogue of failings including mothers being blamed for their infant’s deaths.

The inquiry into deaths and allegations of poor care at the Shrewsbury and Telford Hospital NHS Trust is now examining the cases of 1,862 families.

It comes after 42 babies and 13 mothers died during, or shortly after, childbirth at the trust between 2000 and 2019.

The scandal came to light following campaigning from bereaved families, notably Richard Stanton and Rhiannon Davies, who lost their daughter Kate hours after she was born with anaemia in March 2009.

A report published 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 the trust failed to investigate after babies’ skulls were crushed during repeated attempts to deliver them using forceps – with one dying and another developing cerebral palsy.

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 

Mr Stanton said the trust should ‘hang their heads in shame,’ over today’s report. 

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

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

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

Former senior midwife Donna Ockenden, chair of the independent maternity review, described the initial recommendations – including a call for risk assessments throughout pregnancy – as ‘must dos’ which should be implemented immediately. 

The report said that when completed, the review of 1,862 families ‘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.

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 

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

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 dauhter 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’. 

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.’ 

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.’ 

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

‘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.’ 

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

COULDN’T BE BOTHERED TO DO THEIR JOBS

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. 

Patient safety minister Nadine Dorries said in a statement: ‘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.’ 

West Mercia Police have also launched their 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.  

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

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

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

FAMILY DELIGHT TURNED TO DESPAIR 

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. 

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. 

Read more at DailyMail.co.uk