Almost 300 hundred babies died or suffered serious brain damage at maternity hospitals in Shropshire

The Ockenden Report was published today following a five-year investigation into the standard of maternity care at Shrewsbury and Telford Hospital Trust.

The landmark report has found that 295 babies died or were left brain damaged as result of the failings whilst under the hospital’s maternity care. After hearing the distressing experiences of over 1,800 families between 2000 and 2019, the report also found that 12 mothers lost their lives whilst giving birth at the Trust.

Major concerns over the care provided by midwives and obstetricians were found in 201 cases where babies had died, which included 131 stillbirths and 70 neonatal deaths.  Almost 100 other children suffered life-changing injuries, including cerebral palsy, as a result of avoidable harm due poor maternity care.

The first report on the Trust’s maternity services was published in December 2020, which highlighted the dreadful experiences of families and led to a series of recommendations for improvements.  The initial inquiry reviewed around 60 cases, but the investigation expanded to the largest of its kind as more families whose babies had sadly died or were left permanently injured due to the inadequate care at the Trust came forward to tell of their own experiences.

Today’s report reveals that mothers were denied caesarian sections and forced to suffer a traumatic birth in an alleged bid to hit targets and to achieve ‘natural’ birth at all costs. The report highlights the Trust’s reluctance to perform caesarian sections as well as the ineffective monitoring of babies’ growth.

The report found two fifths of stillbirths and neonatal deaths at the Trust were not investigated internally, which left families without answers and meant that opportunities to learn from mistakes and prevent further death and injury were missed.

Donna Ockenden, the expert midwife who led the Inquiry and who is the author of the Report, spoke to the families alongside her team and expressed how upsetting it was to hear what happened to the babies and how she would often go back to her hotel room after the meetings and cry.

She concluded: “There were numerous opportunities for the system to wake up and realise that there was a problem at this Trust. There have been a number of occasions where families tried to be heard over many years and were silenced or ignored.”

Chief Executive of the Shrewsbury and Telford Hospital Trust, Louise Barnett, offered her wholehearted apologies and said: “Thanks to the hard work and commitment of my colleagues, we have delivered all of the actions we were asked to lead on following the first Ockenden report, and we owe it to those families we failed and those we care for today and in the future to continue to make improvements, so we are delivering the best possible care for the communities that we serve.”

Gill Edwards, Partner in the clinical negligence department at Potter Rees Dolan and a member of the Baby Lifeline Multi-Disciplinary Panel comments:

Sadly, the issues highlighted in the report have been repeated for many years and they are not isolated to this Trust. Poor care will continue in some maternity units until there is greater openness and better sharing of information so that lessons are learned, and standards improve. There are some who suggest that staff are reluctant to be honest about errors because of the fear of litigation and that a no-fault compensation system would work better. I wholeheartedly disagree.

Very often it is the very fact that a legal case has been brought by a family which brings these failings to light, as the process involves an inspection of the care by independent experts. The current legal system also ensures that staff are held accountable for their actions. The NHS needs to share information across all Trusts and properly fund the ongoing maternity training required to reduce repeated errors so that families can have confidence in maternity services again.

Gill Edwards is a Partner in clinical negligence here at Potter Rees Dolan. Should you have any queries about this report, birth injuries or indeed any other aspect of clinical negligence and wish to speak to Gill or any other member of the team, please contact us on 0800 027 2557 or contact Gill directly.​​