Does damning Ockenden report net need to be cast WIDER?

Five NHS trusts in England carry out fewer C-sections than the Shrewsbury maternity unit at the centre of worst maternity scandal in British history, MailOnline can reveal.

A devastating five-year inquiry into hundreds of baby deaths at Shrewsbury and Telford Hospital NHS Trust ruled an obsession with ‘normal births’ contributed to the failings. The landmark 250-page report said the trust forced some women to have vaginal deliveries, often when a caesarean would have been a safer option, to keep surgery rates low. 

Health chiefs hailed the Shropshire trust for its extremely low C-section rates in the years before the probe began, with the major operation making up as few as 15 per cent of deliveries. Its figures have crept up over the past five years. 

NHS England’s most up-to-date performance league table show it still ranks sixth bottom, however, with 26.2 per cent of births being C-sections. 

Hospitals in Suffolk, South Tyneside, Bradford, Lancashire and Cornwall all saw fewer than one quarter of babies delivered through caesareans in 2020/21. Official data reveals the average across the whole of England stood at 33.5 per cent. 

Maternity units were only told last month to stop pursuing ‘normal births’, with the country’s most senior midwife instructing all sites to ‘stop using total caesarean section rates as a means of performance management’ because it was ‘unsafe’. NHS bosses stress low C-section rates do not mean a maternity service is unsafe.

Families of babies who died at the hands of the trust have also warned Shrewsbury is not an ‘isolated case’, and claimed it was likely others have also been pursuing high ‘normal birth’ levels. 

Independent reviews of maternity services are also underway in Nottingham and Kent.

Health Secretary Sajid Javid said yesterday he was ‘absolutely determined’ to ‘go after the people responsible’. He added: ‘I want to make sure that we leave no stone unturned in finding the people responsible for this and making sure that they are held to account.’

Donna Ockenden, the senior midwife who led the review, warned childbirth would not be safe in England until all her recommendations were implemented in full.

The above shows the C-section rates at the five NHS trusts with lower rates than Shrewsbury and Telford in the year to March 2021, back to 2011. It shows these trusts have all been consistently below the England average. * = Royal Cornwall Hospitals have disputed the official NHS statistics for the year to March 2021, and say their rate is 25.6 per cent

Pictured above is the Royal Shrewsbury Hospital at the scandal-hit Shrewsbury and Telford hospital NHS Foundation Trust. An investigation pointed to cases where mothers were forced to have a vaginal birth despite needing a C-section

Donna Ockenden, chair of the Independent Review into Maternity Services at the Shrewsbury and Telford Hospital NHS Trust, presented her devastating report on Wednesday

Separate monthly maternity statistics published by the NHS suggest up to two dozen trusts had a lower C-section rate than Shrewsbury. 

But the trusts argued the figures, although published by the NHS, were not reliable because of reporting delays in hospitals.   

Annual statistics showed Shrewsbury’s C-section rate hovered around the 15 per cent mark in the decade running up to 2015, before the extent of the scandal came to light. 

But they rose above 20 per cent in 2018, just as the trust began to face pressure over its maternity services. Latest statistics show that in the year to March 2021 they reached 26 per cent. 

Minister reveals she was told she wasn’t going to have a C-section

A minister has revealed she was told not to have a C-section, despite enduring a ‘very difficult’ labour with her first child. 

International Trade Secretary Anne-Marie Trevelyan was asked today how she felt about yesterday’s report which found some 201 babies and nine mothers could have survived at Shrewsbury and Telford Hospital NHS Trust if they had got better care.

She told Times Radio that with her first birth she was ‘basically told I wasn’t going to have a Caesarean section’.

Ms Trevelyan, who has two children, said the inquiry, which found several mothers were made to have natural births when they could have been offered a C-section, ‘reminded me that there has been for a long time a culture which says natural birth: good; Caesarean: bad’.

‘And actually this report has highlighted that in too many cases difficult births can end in the most appalling tragedy, and honestly it makes me feel sick thinking that those situations have occurred,’ she said.

International Trade Secretary Anne-Marie Trevelyan (pictured earlier this month) has said she, like many of the women in the Ockenden was advised having a C-section

The Royal Cornwall Hospitals NHS Foundation Trust had the country’s lowest C-section rate last year (15 per cent of all births). The trust disputes this figure, however, and says the true rate is closer to 25 per cent. It said that an incorrect number of births and C-sections were listed in the official NHS data.

It was followed by Lancashire Teaching Hospitals NHS Trust (21.5 per cent) and Bradford Teaching Hospitals NHS Foundation Trust (24.6 per cent).

South Tyneside and Sunderland NHS Foundation Trust (24.9 per cent) and West Suffolk NHS Foundation Trust (25.1 per cent) also had rates below Shrewsbury. 

At the other end of the scale was Guy’s and St Thomas’ NHS Foundation Trust in London, where almost two in five births (39 per cent) were via C-section.

The organisation was followed by Kettering General Hospital NHS Foundation Trust and University College London NHS Foundation Trust (both 39.5 per cent). 

In a letter sent to hospitals in England last month, the health service’s chief midwife Jacqueline Dunkley-Bent and national clinical director for maternity Dr Matthew Jolly told all maternity services to ‘stop using caesarean section rates as a means of performance management’.

They said: ‘We are concerned by the potential for services to pursue targets that may be clinically inappropriate and unsafe in individual cases.’

The Royal College of Midwives formally abandoned its ‘normal birth’ campaign in 2017, after previously praising trusts for keeping these rates low. It now admits to ‘regretting’ that decision.

In July last year a health committee report also recommended this should be scrapped, adding that it was ‘deeply concerning’ that maternity services had been penalised for having high rates in the past.

Speaking yesterday, Mr Javid said he was ‘appalled’ by the conclusions of the Ockenden review, which probed up to 1,600 cases spanning largely between 2000 and 2019. One incident referred to the investigation dated back to the 1970s. 

He told reporters it was right the Government had accepted the report’s recommendations ‘to make sure this kind of thing never happens again’.

‘But it’s also right, and I’m absolutely determined to do this, that we make sure we go after the people responsible,’ he said. ‘Of course there were systemic failures, we must change systems, but there were also individual failures.’

Richard Stanton, whose daughter, Kate, died in 2009 as a result of what he described as the trust’s ‘abhorrently poor care’, warned the type of failures his family experienced were not limited to just one trust.

He said: ‘I don’t think Shrewsbury and Telford is an isolated case. I think they’re an extreme case in terms of where they are in numbers. That doesn’t mean this isn’t happening anywhere else.’

Health leaders have also warned that babies and mothers are being put at risk in England over a shortage of midwives.

The number of midwives employed in the NHS in England has fallen to 26,901, according to figures published last month.

This is down from 27,272 a year ago, with the Royal College of Midwives warning it adds to an existing shortage of 2,000 staff.

Rhiannon Davies (left) embraces Kayleigh Griffiths yesterday following the release of the Ockenden report. Both women were instrumental in campaigning for an inquiry into poor maternity care at Shrewsbury and Telford Hospital NHS Trust which led to then health secretary Jeremy Hunt ordering one in 2017 

The devastating Ockenden report said an obsession with ‘normal births’ had contributed to the biggest maternity scandal in NHS history.

Ms Ockenden blamed eight external bodies in part for allowing the litany of errors that resulted in 201 babies and nine mothers dying in avoidable circumstances.

In one case the Care Quality Commission, which regulates the NHS in England, had even rated the maternity ward at the Trust as ‘good’.  

The landmark 250-page report found the trust ignored the concerns of many parents and failed to learn from its own inadequate investigations.

This led to babies being stillborn, dying shortly after birth or being left severely brain damaged.

Some infants suffered skull fractures, broken bones or developed cerebral palsy after traumatic forceps deliveries. Others were starved of oxygen and had life-changing brain injuries.

Staff were found to be frightened to speak out about errors due to the ‘culture of undermining and bullying’, while bosses ignored parents who raised concerns about how they were treated.

There were issues with staffing, the management of patient safety, patient and family involvement in care and investigations, as well as the complaints processes.

There are also investigations into maternity services underway at Nottingham University Hospitals NHS Trust, one of the largest in England.

It has been launched after it emerged incidents were not reported to NHS England or local health bosses, giving the impression that there were fewer errors happening on maternity wards compared to other areas.

Maternity services at East Kent Hospitals NHS Foundation Trust are also under investigation, which last year was fined £733,000 over serious failures that led to the death of baby Harry Richford.

An NHS spokesperson said: ‘The NHS has already reminded maternity services that caesarean section rates should not be used as a means of performance management.

‘There is no “correct” number for c-sections – each birth is different and it is important that every pregnant woman and her maternity team are able to discuss and assess the risks and benefits of each delivery method as part of a personalised care and support plan, to ensure the best possible outcome for mums and their babies.’

A DHSC spokesperson said: ‘The Ockenden report paints a tragic and harrowing picture of repeated failures in care over two decades at Shrewsbury and Telford NHS Hospital Trust.

‘The Health and Social Care Secretary has been clear that we will leave no stone unturned in addressing these systemic failures and pursuing the individuals responsible to make sure they are held to account.

‘It’s vital that across maternity services, NHS trusts focus on safe, personalised care, where the voice of the mother is heard throughout.’

Timeline: How the Shrewsbury maternity scandal unfolded 

2002

A parliamentary report highlights how Shrewsbury and Telford Hospital Trust (SaTH) has one of the lowest caesarean rates in country, at just 10 per cent of births.

2007

A leading number of maternity organisations sign a ‘normal birth consensus statement’ discouraging medical interventions like caesareans where possible.

At this time then health regulator, the Health Care Commission warns SaTH there were issues in how staff were monitoring foetal heart rates after incidents where babies were injured.

2009

Kate Stanton-Davies dies just hours after being born while under the care of Shrewsbury staff. Her parents begin to campaign for an investigation into what went wrong.

2013

Pictured: A file photo showing the entrance to the Royal Shrewsbury Hospital in Shropshire

Shrewsbury’s maternity services faced an internal investigation in 2013, but it concluded it was  ‘safe’ and of ‘good quality’.

2015

An inquiry into failings at Morecambe Bay NHS trust – where 11 babies and one mother suffered avoidable deaths – found a group of midwives’ overzealous pursuit of natural childbirth had ‘led at times to inappropriate and unsafe care’.

It said the entire NHS should learn from the failings observed.

2016

Pippa Griffiths dies shortly after being born while being cared for by Shrewsbury staff.

Her parents join forces with Kate Stanton-Davies’s mother and father in calling for an investigation into maternity services at the trust.

A birdseye view shows the sprawling Royal Shrewsbury Hospital in Shropshire on the outskirts of the town from above

2017

Then health secretary Jeremey Hunt orders an inquiry into the trust which will eventually be headed by midwife Donna Ockenden. The original scope of the inquiry encompasses just 23 cases. 

2018  

Former health secretary Matt Hancock said the Ockenden review is being expanded to include hundreds of cases.

Also in this year the trust is rated inadequate for safety by health watchdog the Care Quality Commission. 

2020

Pictured: A general view of The Princess Royal Hospital in Telford, Shropshire, which is also part of the scandal-hit trust 

Ms Ockenden announces the investigation is now looking at cases involving 1,862 families and releases early recommendations ahead of the full report.

2021

The inquiry findings are delayed to 22 March 2022 due to an influx of new information from Shrewsbury and Telford Hospital Trust. The final report was originally due in December 2021. 

2022  

The report is delayed again this time by a few weeks due to ‘parliamentary processes’. 

Today’s final report detailing the harrowing scale of deaths and injuries among babies and women over two decades of the trust’s care is published.

Midwives’ missed chances to save baby Pippa from deadly infection:

Pippa Griffiths could still be alive today had midwives realised she was suffering a deadly infection. The little girl was born at home in Shropshire in April 2016, but died just 31 hours later from a Group B Streptococcus infection.

A coroner ruled her death was avoidable and blamed a string of unforgivable errors by midwives.

The inquest heard medical staff missed a crucial opportunity to save Pippa when her mother Kayleigh rang a midwife with concerns about her baby’s feeding.

A second chance to save Pippa’s life was missed when her mother rang hours later to report bloody mucus, a sign of a serious bacterial infection which could have been treated with urgent hospital treatment.

Mrs Griffiths wipes her eyes as she holds the Ockenden report at The Mercure Shrewsbury Albrighton Hotel in Shropshire

The couple (pictured with their baby) lost Pippa a day after she was born in 2016 due to midwives failing to spot the serious infection Group B Strep – even though Kayleigh warned them

Pippa was born at 8.34am and a midwife was supposed to have gone to the family home for a check-up later in the afternoon.

But the inquest heard she failed to turn up. Pippa developed a purple rash later that night and eventually stopped breathing. Emergency services managed to get her breathing again, but she later died.

The trust accepted that chances to save Pippa’s life were missed. Following the conclusion of the inquest, Mrs Griffiths said: ‘We’ve fought for her and fought for the truth and ultimately she could have been saved.’

Mother said she’d lost fluid but was told she’d probably wet the bed… but had a stillbirth

Charlotte Jackson raised concerns with staff that she had lost fluid and her baby’s movement had reduced when she was 37 weeks pregnant.

Workers told her she had likely just wet herself, but he son – Jacob Harris – was was stillborn in November 2018 at Telford hospital.

The then 29-year-old from Bridgnorth got lawyers involved and the hospital trust admitted liability and agreed a settlement.

She told the Shropshire Star: ‘I was quite worried and upset. Jacob had always been a very active baby so when I noticed that his movements were reduced I had a gut feeling that something was not right.

‘However, I was shocked when I was told that it was a one off and I’d probably wet the bed.’

She later added: ‘Giving birth to Jacob was absolutely horrific. It’s almost impossible to put into words the emotion of it all, knowing your baby had already died.’

Workers told her she had likely just wet herself, but he son – Jacob Harris – was was stillborn in November 2018 at Telford hospital. Pictured: The baby’s grave

 Reverend said her son looked unwell after being born – but was dismissed by staff:

The Rev Charlotte Cheshire, 44, from Newport, Shropshire, said her son Adam, now 11, looked unwell after his birth in 2011 but her concerns were dismissed by staff at the trust.

When it was finally discovered he had Group B Strep infection, he was rushed to intensive care where he stayed for almost a month.

Ms Cheshire, who is suing the trust, said her son has been left with multiple, severe health problems and should have received treatment much earlier.

Ms Cheshire, who is suing the trust, said her son has been left with multiple, severe health problems and should have received treatment much earlier for Adam (pictured)

The Rev Charlotte Cheshire, 44, from Newport, Shropshire, said her son Adam, now 11, looked unwell after his birth in 2011 but her concerns were dismissed by staff at the trust

She said: ‘What I’m ultimately hoping is that all of the families get some answers.

‘And then, in our individual cases, about how it’s possible for there to be such systemic failings over so many years, with seemingly either no-one noticing them, or potentially them being covered up.

‘So I’m hoping first of all for answers, but secondly, I’m hoping, as a result of Ockenden, there are genuine learnings.

‘Not the sort of, ‘oh, we’ll learn and get back to you’, but genuine learnings to improve maternity safety – primarily first of all at Shrewsbury and Telford, but secondly across the country as a whole.’

She added: ‘I don’t want any other family to have to go through what we’ve gone through.’

Jack Stephen Burn died 11 hours after being trapped in the birth canal for four minutes. His mother Hayley Matthews (pictured) had been told that nothing was wrong with her pregnancy but later found out that Jack had been distressed for 20 minutes before delivery

Baby boy died 11 hours after being trapped in birth canal for FOUR MINUTES:

Jack Stephen Burn died 11 hours after being trapped in the birth canal for four minutes.

His mother Hayley Matthews had been told nothing was wrong with her pregnancy but later found out Jack had been distressed for 20 minutes before delivery.

He had also contracted group B streptococcus, the lethal infection carried by one in five women.

Jack died in March 2015 at the Princess Royal Hospital in Telford, hours after another baby, Oliver Smale, died following similar complications. Oliver’s death was later deemed avoidable.

Although Jack’s death was not deemed avoidable, it was later considered part of the investigation.

Miss Matthews, from Chirbury, west Shropshire, previously said: ‘We would have both been in the hospital at the same time and there are so many parallels between the two cases.

‘As with this poor boy, Jack got his shoulder stuck during delivery.

‘They just left his head hanging while they went off to get someone to do something about it.’

A post mortem examination revealed that Jack had been starved of oxygen and had an infection on the lung and pneumonia caused by strep B.

Miss Matthews is campaigning for routine screening of strep B, which is not NHS policy. She said: ‘If I’d have been tested for strep B during my pregnancy they might have picked up on it and given me antibiotics at an earlier stage and this means that Jack might still be alive today.’

Jack Stephen Burn (pictured) died 11 hours after being trapped in the birth canal for four minutes

Rhiannon Davies had raised fears over reduced movement in the womb

Staff ignored mother’s warnings and said she was ‘low-risk’ despite daughter being born ‘pale and floppy’:

Kate Stanton-Davies died six hours after she was born because midwives failed to spot tell-tale signs of her deteriorating health.

Her mother Rhiannon Davies had raised fears over reduced movement in the womb, but was ignored by midwives who failed to properly monitor her pregnancy and wrongly deemed it low-risk.

Kate, who had anaemia, was born pale and floppy at Ludlow Community Hospital in Shropshire in March 2009. She was airlifted to Birmingham’s Heartlands Hospital but died.

A report published in February 2016 concluded her death was avoidable and identified a litany of failings and shoddy record-keeping at the Shrewsbury and Telford trust.

Two midwives were deemed responsible for the errors, which included changing Kate’s observation notes after her death.

Mrs Davies said: ‘You would think losing Kate would be the worst event in my life but the continual need to revisit the trauma of that day as we fight to get the truth means my distress is ongoing.

‘How many other baby deaths were avoidable, how many other investigations were not fit for purpose, how many other families have been betrayed, and how many other opportunities for learning have been lost?’

Kate Stanton-Davies died six hours after she was born because midwives failed to spot tell-tale signs of her deteriorating health

Katie Wilkins’ baby girl died at Shrewsbury Hospital after midwives left her in a side room for 48 hours and failed to properly monitor her. Miss Wilkins pictured with partner Dave Jackson, 45

‘My girl was still born after I was left in a side room’:

Katie Wilkins’ baby girl died at Shrewsbury Hospital after midwives left her in a side room for 48 hours and failed to properly monitor her.

Miss Wilkins was 15 days overdue when she arrived at the hospital to be induced in February 2013.

There were no beds available on the busy labour ward and Miss Wilkins, 24, claims she was ‘forgotten’ in the room for two days and visited by staff just a handful of times.

When a midwife did come to check on her progress they realised her baby’s heartbeat could not be found. Maddie was delivered stillborn in the early hours of the following day.

Hospital bosses later admitted the baby would have been born alive had they treated her in a more ‘timely’ manner.

Miss Wilkins said: ‘Maddie’s death was recorded as unexplained but we know why she died – because the midwives didn’t do their jobs properly.

‘I’d had a perfectly normal pregnancy and didn’t expect any problems with the birth. But I was left for hours at a time. The hospital was very busy and I felt like they simply forgot about me.

‘Giving birth to my stillborn daughter was heartbreaking. I should have been taking her home with me, but instead she had to stay at the hospital in a Moses basket. It was awful.’

Maddie was delivered stillborn in the early hours of February 21. The results of a post-mortem examination said the 6lbs 14oz baby girl’s death was unexplained.

In a letter to Miss Wilkins, Cathy Smith, head of midwifery at the hospital, apologised and admitted: ‘Had your induction occurred more timely, Maddison would likely to have been born alive.’ She added that practices at the hospital had now changed.

Miss Wilkins – who has since had a son and daughter with her partner Dave Jackson, 45, – is sceptical. She said: ‘We were told that changes would be made and women would be properly monitored, but now it seems that never happened. The hospital think they can say sorry and we should move on, but we can’t.’

Staff told her she was not suffering an abruption despite severe pains… when she was

Steph Hotchkiss from Telford started to suffer severe pains in September 2014 when she was nearly 31 weeks pregnant and asked if she was having an abruption.

Staff told her she was not, but they were wrong and baby Sophiya passed away just 32 hours later. Steph told the Shropshire Star she still suffers flashbacks of the trauma, caused by a ruptured placenta.

The then 28-year-old had similar issues when her son Kyan was born in 2013, and then had an emergency caesarian.

But she said staff refused to listen to her during her daughter’s birth, with her having told Royal Shrewsbury Hospital staff what she thought was happening.

She said: ‘I can’t put into words how painful this is for us. It was just so frustrating not to be listened to when I had previously had a difficult pregnancy involving a similar thing.’

Steph Hotchkiss from Telford started to suffer severe pains in September 2014 when she was nearly 31 weeks pregnant and asked if she was having an abruption

Encouraged to give birth naturally before baby got stuck and had to have emergency caesarean

Kamaljit Uppal was on the way to having her third child in 2003 but was told it would have to be delivered by caesarean because of how he was lying.

But staff at the Royal Shrewsbury Hospital encouraged her to give birth naturally and she went through 18 hours of labour.

The baby got stuck and Kamaljit had to have an emergency caesarean. She said: ‘I’m still coming out of my general anaesthetic and she said ‘he’s died’ and that’s it. They plonked the baby in my arms and said say goodbye.

‘I didn’t know how to say goodbye, I gave him a kiss and that was it. Once I came around a bit more they put me in a ward where there were babies.’    

Kamaljit Uppal was on the way to having her third child in 2003 but was told it would have to be delivered by caesarean because of how he was lying. Pictured: She still keeps the baby’s unworn clothes

Lost one of her twins during labour:

Debbie Greenaway lost one of her twin babies during labour at the trust and said the report ‘doesn’t change what’s happened for 20 years’.

She told This Morning: ‘To begin with, we thought it was just us, we had no idea until they started the report that exactly the same story has happened to so many people.

‘There were so many similarities… I wanted to tell my story and raise that awareness and give women a voice.’

‘Consultants came and went, there was no communication, I didn’t know what drugs I was being given or why, one consultant – I learnt afterwards was trying to take a foetal blood sample from John – which basically they cut his head to find his oxygen level, but they never explained what they were doing. I thought she was delivering them…

Debbie Greenaway lost one of her twin babies during labour at the trust and said the report ‘doesn’t change what’s happened for 20 years’

‘[At the start of my pregnancy] a c-section delivery was straight away brushed off with ‘we have the lowest caesarean rate in the country, we’re proud of it, there’s no reason for you not to have a natural birth’…’

She had an emergency caesarean, with Debbie saying, ‘When I woke up, all I remember was my husband handing me Daniel, I went, ‘Where’s John?’ and again, another doctor I’d never seen before said, ‘There’s nothing we can do, we need to turn the life support off’… and before I could react to that he walked off and came back carrying John.

‘And in my just come round state, I thought ‘Oh I got that wrong, he’s here, he’s fine’ and when he was handed to me I actually thought he was alive.’

Following a post mortem, she said: ‘All of the time frame was between me going in with two healthy babies with absolutely no issues and an awful long time from when he was brain damaged to delivery…’ 

We lost our only child at 4 days

Katie Anson’s son Kye died after just four days of life due to failures at the scandal-hit trust.

The baby was starved of oxygen in birth at Princess Royal Hospital, Telford, in 2015, but a coroner later heard he may have lived if staff had acted differently.

Miss Anson, 39, and partner Matthew Hall, 34, from the town, were unable to have another child due to unexplained infertility.

Katie Anson and her partner Matthew Hall

Kye died at New Cross Hospital in Wolverhampton. A 2016 inquest heard some heart rate recordings of the unborn baby had not been taken.

Shrewsbury coroner John Ellery said his death ‘could have been prevented’. The couple struggled to get pregnant for two years before Kye. They have just had their sixth failed attempt at IVF.

Miss Anson said: ‘To have had our only child taken away from us so tragically… makes it all the more difficult to swallow.’