November 20, 2019

The largest maternity scandal in NHS history? What a leaked report tells us about Shrewsbury and Telford Hospital Trust

Until now, The Morecambe Bay hospitals scandal, which saw the avoidable deaths of 11 babies and one mother at Cumbria’s Furness general Hospital between 2004 and 2013, was described as the worst ever maternity scandal in the history of the NHS.

Today however, The Independent has thrown this into question by highlighting the appalling care afforded to parents and babies at the Shrewsbury and Telford NHS Trust for a period of some 40 years. The Independent has obtained the interim update report from an independent inquiry ordered by the Government in July 2017 into the care provided by the Maternity Unit at The Shrewsbury and Telford Hospital NHS Trust for a 40 year period from 1979.

The inquiry, which is being led by maternity expert Donna Ockenden, was launched by former Health Secretary Jeremy Hunt following the efforts of Mr and Mrs Stanton Davies whose daughter Kate died shortly after birth in 2009, and Mr and Mrs Griffiths whose daughter Pippa died shortly after her birth in 2016.

Its initial scope was to examine 23 cases but this grew significantly and with more cases still being reported it is thought that the number will grow further still.

What does the leaked report tell us?

This leaked report highlights how dozens of mothers and babies died on wards of the Shrewsbury and Telford Hospital Trust due to the major and repeated failings of doctors, midwives and hospital management. A failure to learn from mistakes was reported to be present from the earliest case of a neonatal death in 1979 and continued to be an issue in cases occurring at the end of 2017. This failure to learn lessons allowed the malpractice to continue.

Continued failings not being addressed

A common theme in the report is that failings have been identified to have continued over this whole 40 year period rather than being individual incidences. For example, there was a continued failure to obtain informed consent from mothers choosing to deliver their babies in midwifery led units. The risks associated with delivering a baby in such a unit, should something go wrong, were not discussed, leaving mothers ill informed with sometimes catastrophic consequences.

A lack of transparency

Other failings identified included a lack of transparency, honesty and communication with families after things had gone wrong. This is directly contrary to the legal duty of candour which is now in force.

There were also failings in respect of recognition of serious incidents and not involving families in investigations. When investigations were carried out they were often poor and described as extremely brief and overly defensive of staff.

A lack of care and support for those who experienced loss

Sadly, it also identified that there was a complete lack of kindness, support and respect for the families involved, who had obviously gone through the worst tragedy that any family could ever expect to go through.  There were many examples of deceased babies being referred to by the wrong names and even referred to as “it”. One family was event told that they would have to leave if they did not “keep the noise down” when they were upset following the death of their baby.

Heartbreakingly, it was reported that a baby’s body was even allowed to decompose over a period of weeks after a post mortem examination meaning that it prevented the mother from seeing her child one final time before burial.

‘Misplaced optimism’

The report reveals that regulators were aware of the problems as far back as 2007 but nothing was done due to ‘misplaced optimism’. There is also suggestion of an inadequate review carried out by the Royal College of Obstetricians and Gynaecologists in 2017 and long standing culture at the Trust that is toxic to improvement effort. The Trust have even been criticised in respect of their slow response in sending the inquiry medical records, clinical notes and other documents.

The inquiry is set to continue.

This is an extreme example of a hospital trust’s maternity unit being poorly managed and, at times, almost cynically run. However, at a time when we’re seeing hospital trusts under increasing pressure due to staffing shortages and other institutional problems, it is concerning that even ten years ago serious problems were occurring at this scale, and seemingly left to, in just one unit of one hospital trust.

As solicitors who sometimes deal with cases involving the death of an infant, we see at first hand the unimaginable pain and suffering this causes to families. That these incidents happened at such scale, and were left unaddressed for so long, is shocking. Although even without these systemic failings deaths may still occur, our hope is that in future families do not even come close to experiencing the level of hurt of some of those who attended the Shrewsbury and Telford Hospital Trust’s maternity unit over this time period.

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