More than 200 babies may have died due to repeated failures at an NHS trust, a report says.
A major review looked into a series of serious and fatal obstetric incidents in Shropshire and found a series of “repeated errors” spanning 20 years.
The Ockenden review found 201 babies could have survived had Shrewsbury and Telford Hospital NHS Trust provided better care Sky news dubbed “the worst maternity scandal in NHS history”. In other cases, mothers died and babies were left brain-damaged.
“Bereaved mothers were blamed for the deaths of their babies,” said the channel, noting that more than 1,500 cases were reviewed between 2000 and 2019. Hundreds of families came forward after independent midwife Donna Ockenden was asked to investigate 23 cases of concern in 2017.
The guard said the “damning” report condemned the trust for “blaming mothers while they repeatedly ignored their own catastrophic mistakes for decades.”
Where cases were investigated, responses lacked “transparency and honesty,” said the report, which also uncovered a culture of bullying, fear and a fear of speaking out among trust staff.
The review examined catastrophic failures and found that “failures in care were repeated from one incident to the next.”
Families of babies who died or were left severely disabled because of mistakes made by the Trust received the final report of the independent inquiry this morning.
“We now know this is a trust that failed to investigate, failed to learn and failed to improve,” said lead midwife Donna Ockenden, who led the review. “This resulted in tragedy and life changing incidents for so many of our families.”
A former consultant obstetrician-gynaecologist, who previously worked for the Trust for almost 30 years, told the BBC’s Panorama program what he believes has contributed to the Trust’s failure.
Bernie Bentick, a former consultant obstetrician-gynaecologist at Shrewsbury and Telford Trust, said he had emailed the hospital’s management on several occasions describing “incidents of a dysfunctional culture, of bullying, of the imposition of changes in the clinical practice highlighted by many clinicians as unsafe”.
Bentick explained that “the unit’s resources are scarce,” and former staff also stressed that shortages of midwives and counselors had been a problem for a number of years. As a result, Bentick says, “there has been a tendency to blame individuals for not following guidelines rather than looking at the underlying factors that may have led to a particular problem, particularly the staffing level in the midwifery department.”
Today, Ockenden concluded: “There was not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and leadership at the Trust, and a culture where affected families were not listened to.” She added what was “amazing”. , is that these issues have not been officially challenged for more than two decades.
Push for caesarean section
The Trust also has a “culture of low cesarean rates” that BBCSocial affairs correspondent Michael Buchanan told Radio 4 today program Last month. At one point the hospital was performing the lowest number of caesareans in England and although there was a national effort at the time to reduce the number of caesareans being performed, Buchanan said it appeared the Trust was using this guidance ” too vigorously”.
The Sunday Times described the “dogma” for natural births over cesarean sections as “put into practice by a group of faceless and often unaccountable public bodies” whereby “a consensus has formed around a fashionable but unscientific set of ideas”. The scandal was “uniquely grotesque in the 21st century,” the newspaper said, and “ideologies must never again stand in the way” in order to reduce maternal and child mortality.
“Unorthodox” system for reviewing cases
Part of the reason for the prolonged lack of care also appears to be that NHS regulators were not necessarily aware of the incidents and patient complaints. A first report The report, released in December 2020, highlighted that “in many cases the Trust did not investigate after something went wrong, or simply conducted its own investigation,” Buchanan said.
Panorama also revealed that the Trust “developed their own investigative system, which they dubbed the High Risk Case Review.” This “unorthodox” system does not appear to have been used “in any other NHS organisation”, Buchanan said. This resulted in fewer incidents being reported to NHS regulators, “reducing the ability to learn lessons”.
https://www.theweek.co.uk/news/science-health/955857/shrewsbury-telford-maternity-scandal Ockenden recap: How Britain’s biggest maternity scandal unfolded