March 31, 2022 – More than 200 babies died in a pair of British hospitals, and an investigation has found failure in maternity care is likely to blame.
A review into the care of babies and mothers who died at Shrewsbury and Telford NHS Hospital Trust found repeated failures in the quality of care and governance spanning two decades.
The report, which examined cases involving 1,486 families and 1,592 incidents between 2000 and 2019, also identified repeated failures to effectively monitor the care provided.
The independent review of maternity services suggests that 131 of the 498 stillbirths in this period might have been avoided if better care had been given. There were an additional 17 cases of neonatal death, 10 cases of cerebral palsy/brain damage, and two cases of brain damage caused by a lack of oxygen where care had been lacking.
Out of 12 maternal deaths reviewed, nine cases were identified where there were significant or major concerns in the care received.
Deaths Were Often Not Investigated
The report also found that 40% of the 168 stillbirths, and 43% of the 77 neonatal deaths, during this period were not investigated by the National Health Service.
The report found that the NHS Trust on several occasions blamed mothers for the deaths or injury to their children, and that officials sometimes blamed mothers for their own deaths.
Louise Barnett, the Trust's chief executive, described the findings as "deeply distressing" and offered "wholehearted apologies" to those affected.
The Nursing and Midwifery Council described the failings as "appalling."
Insufficient Staff and Shortcomings in Training
The investigation began in 2017 when then-Health Secretary Jeremy Hunt began to look into 23 deaths at the hospitals. Since then, many more families came forward. Interim findings released in December 2020 were based on a review of 250 cases in which families had shared with investigators "the overwhelming pain and sadness that never leaves them.”
In the final report, the reasons for the failings were clear, officials said: "There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the Trust, and a culture of not listening to the families involved."
"Failures in care were repeated from one incident to the next," senior midwife Donna Ockenden, who led the investigation, said. "For example, ineffective monitoring of fetal growth and a culture of reluctance to perform Caesarean sections resulted in many babies dying during birth or shortly after their birth. In many cases, mother and babies were left with life-long conditions as a result of their care and treatment."
At a news conference, Ockenden said investigators were "deeply concerned" that families continued to contact the team with reports they wanted to share.
Responding to the report, the Trust's Louise Barnett said: "Today's report is deeply distressing, and, on behalf of all at the Trust I offer our wholehearted apologies for the pain and distress that has been caused.”
Barrett said the Trust takes “full responsibility for our failings.”
She said the Trust has implemented all changes that the investigation suggested.
"We know that we still have much more to do to ensure we deliver the highest possible standard of care to the women and families we care for,” she said.