Shrewsbury & Telford Hospital: Babies & mums died 'amid toxic culture'
- 22.11.2019
- JessicaMG
- Clinical-negligence, Clinical-negligence, Clinical-negligence, Clinical-negligence
It has been revealed, in a report leaked to the Independent, that dozens of mothers and babies died amid a “toxic” culture at Shrewsbury and Telford Hospital NHS Trust (SaTH) in what is being described as 'the largest maternity scandal in NHS history' .
The leaked report has exposed a catalogue of maternity care failings spanning a total of 40 years, which include the deaths of dozens of mothers and babies, children left disabled and staff getting the names of deceased infants wrong, at times even referring to babies as 'it'. In one particularly shocking case, a baby’s body was allowed to decompose over a period of weeks after a post-mortem examination, reaching such a point it prevented the mother seeing her child one final time before burial.
Jeremy Hunt, then Health Secretary, announced an investigation into avoidable baby deaths at the trust back in 2017, focusing on a total of 23 cases. However, this has now increased to over 270 cases, some of which date back to 1979. These cases include:
- 22 stillbirths
- Three deaths during pregnancy
- 17 deaths of babies after birth
- Three deaths of mothers
- 47 cases of substandard care
- 51 cases of cerebral palsy or brain damage
The interim report said the number of cases it has now been asked to review "seems to represent a longstanding culture at this trust that is toxic to improvement effort".
The report details the issues experienced by families affected, including:
- Babies left brain-damaged because staff failed to realise labour was going wrong, or from group B strep or meningitis that can often be treated by antibiotics
- Heartbeats not monitored adequately during labour
- One father gaining his only feedback on his daughter's death after bumping into a hospital employee at a supermarket
- Family members being told they would have to leave if they did not "keep the noise down" when they were upset following their baby's death
- A baby girl's shawl, which her mother had planned to bury her in, was lost by staff
- Multiple families "where deceased babies are given the wrong names by the trust - frequently in writing" and "on occasions referred to a deceased baby as 'it'"
It also points to an inadequate review carried out by the Royal College of Obstetricians and Gynaecologists (RCOG) in 2017 and the "misplaced" optimism of the regulator in charge in 2007.
Maternity expert Donna Ockenden, who authored the report for NHS Improvement, is leading the investigation.
Rhiannon Davies and Richard Stanton, whose baby Kate died in 2009, were among the families who first called for the independent inquiry. Ms Davies said she was already aware of many of the issues raised by the report but said she was "shocked" by the period of time the report covered.
"The devastating reality of Kate's avoidable death, that I have to live with, is that she was condemned to her painful death by the culture at SaTH that wilfully refused to learn from earlier cases dating back decades," she said.
"That is why I have fought every body and every institution in Kate's name because no other baby will suffer the same harm while I have breath in my body.
"The only way I believe it will stop is if the police or Crown Prosecution Service bring corporate manslaughter charges against the trust."
Helen Budge, Senior Clinical Negligence Solicitor, comments here:
This is a shocking report and tragically not the first time that an NHS Trust has been found to have a culture which poses a fundamental risk to the well-being of mothers and babies. Any policy, no matter how well intentioned, which puts patients at risk of avoidable harm or violates consent must be reconsidered urgently to avoid further tragedies. That there is evidence of dead babies and bereaved relatives being treated with contempt by staff makes this all the more sickening.
Helen is a Senior Solicitor within our Clinical Negligence team. If you would like to speak to Helen or another member of the team regarding Clinical Negligence, or indeed any other aspect of this article, please call 0800 027 2557 or fill out the contact form at the side of this page. Alternatively, you can contact Helen directly here.