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AT A GLANCE: KEY POINTS FROM THE OCKENDEN REPORT 

  • The inquiry, which examined cases involving 1,486 families mostly from 2000 to 2019, found ‘repeated errors in care’ which led to injury to either mothers or their babies
  • Maternity expert Donna Ockenden, who led the review, said the trust ‘failed to investigate, failed to learn and failed to improve’
  • Some 201 babies and nine mothers could have – or would have – survived if the trust had provided better care
  • Staff were frightened to speak out about failings amid ‘a culture of undermining and bullying’
  • Medics were advised by trust managers not to take part in a ‘staff voices’ initiative set up to assist the investigation into what went wrong
  • Issues were also identified with staffing levels, the management of patient safety, patient and family involvement in care and investigations, and the complaints processes
  • The review team identified 15 ‘immediate and essential actions which must be implemented by all trusts in England providing maternity services’
  • Ms Ockenden said it is absolutely clear that there is an urgent need for a robust and funded England-wide maternity workforce plan starting right now, without delay, and continuing over multiple years
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Police probing a brutal mother-blaming hospital trust at the centre of the biggest ever maternity scandal to strike the NHS are now investigating 600 cases, Sajid Javid announced today.

A damning five-year inquiry, published today, revealed 201 babies and nine mothers died needlessly during a two-decade spell of appalling care at the Shrewsbury and Telford Hospital NHS Trust. 

The landmark probe found mothers were blamed for their own deaths and their ‘poor outcomes’.

Babies suffered skull fractures, broken bones or developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen or experienced life-changing brain injuries. In one case, cleaners binned vital information which was stored on Post-it notes – causing ‘tragic consequences for a newborn and her family’.

Donna Ockenden, the senior midwife behind the scathing probe into almost 1,600 incidents, ruled that the organisation ‘failed to investigate, failed to learn and failed to improve’. 

She added: ‘This resulted in tragedies and life-changing incidents for so many of our families.’

Ms Ockenden also revealed families were still coming forward with examples of poor care suffered at the hands of the trust as recently as 2021, and that one case dated back to the 1970s. 

Staff were found to be frightened to speak out about errors due to the ‘culture of undermining and bullying’, while bosses ignored parents who raised concerns about how they were treated. 

There were issues with staffing, the management of patient safety, patient and family involvement in care and investigations, as well as the complaints processes.

Medics also discouraged C-sections as part of a drive to push up natural birth rates, which Ms Ockenden claimed ‘resulted in many babies dying during birth or shortly after’.

External health authorities failed to adequately investigate serious incidents with families themselves denied access to reviews of their care.

Ex-Health Secretary Jeremy Hunt, who originally ordered the probe back in 2017 to examine just 23 cases of poor care, said the scale of the failures shown in report was ‘beyond his darkest fears’. He said a ‘natural birth ideology’ had pressured mothers to avoid C-sections even when ‘that might have been the safer option’. 

Mr Javid, currently in charge of the Department of Health, called the findings of the Ockenden report ‘tragic’ and ‘harrowing’ with poor care turning what should have been moments of joy and happiness for families into ‘unimaginable trauma’.

He told MPs today that a ‘number’ of staff involved in the scandal have already been suspended or struck off, and that around 600 cases are actively being investigated by police under an investigation named ‘Operation Lincoln’. Mr Javid also said the individuals responsible for the serious and repeated failures will be ‘held to account’.

West Mercia Police, the force carrying out the probe, said no arrests had yet been made but that it would examine whether a criminal case could be brought against either the trust or individuals involved.

Meanwhile, Richard Stanton, whose daughter Kate Stanton-Davies died shortly after being born under the Trust’s watch in 2009, described the report as a ‘watershed moment’ for the NHS. He added: ‘I hope the police will now have sufficient evidence to present to the CPS for a prosecution.’

Another parent of a child who died said ‘for every baby, justice is coming’.

Trust chief executive Louise Barnett today apologised for the pain the affected families had endured. But another grieving parent, Kayleigh Griffiths, said the organisation’s ‘words aren’t going to be enough’.

Prime Minister Boris Johnson told the House of Commons: ‘Every woman giving birth has the right to a safe birth and my heart therefore goes out to the families for the distress and suffering they have endured.’

Rhiannon Davies and Richard Stanton with a copy of the Donna Ockenden Independent Review into Maternity Services at the Shrewsbury and Telford Hospital NHS Trust. Mr Stanton hopes that police now have enough evidence to prosecute those responsible for his daughter's death

Rhiannon Davies and Richard Stanton with a copy of the Donna Ockenden Independent Review into Maternity Services at the Shrewsbury and Telford Hospital NHS Trust. Mr Stanton hopes that police now have enough evidence to prosecute those responsible for his daughter's death

Rhiannon Davies and Richard Stanton with a copy of the Donna Ockenden Independent Review into Maternity Services at the Shrewsbury and Telford Hospital NHS Trust. Mr Stanton hopes that police now have enough evidence to prosecute those responsible for his daughter’s death

Rhiannon Davies from Ludlow, Shropshire, pictured with her daughter Kate moments after she was born on March 1, 2009 at Shrewsbury and Telford NHS Trust. Kate died just hours later

Rhiannon Davies from Ludlow, Shropshire, pictured with her daughter Kate moments after she was born on March 1, 2009 at Shrewsbury and Telford NHS Trust. Kate died just hours later

Rhiannon Davies from Ludlow, Shropshire, pictured with her daughter Kate moments after she was born on March 1, 2009 at Shrewsbury and Telford NHS Trust. Kate died just hours later

Rhiannon Davies (left) embraces Kayleigh Griffiths, both women were instrumental in campaigning for an inquiry into poor maternity care at Shrewsbury and Telford Hospital NHS Trust which led to then health secretary Jeremy Hunt ordering one in 2017

Rhiannon Davies (left) embraces Kayleigh Griffiths, both women were instrumental in campaigning for an inquiry into poor maternity care at Shrewsbury and Telford Hospital NHS Trust which led to then health secretary Jeremy Hunt ordering one in 2017

Rhiannon Davies (left) embraces Kayleigh Griffiths, both women were instrumental in campaigning for an inquiry into poor maternity care at Shrewsbury and Telford Hospital NHS Trust which led to then health secretary Jeremy Hunt ordering one in 2017 

Rhiannon Davies (left) embracing midwife Donna Ockenden (right)on the release of the report into maternity services which released its findings today after a five year investigation which was delayed on multiple occasions

Rhiannon Davies (left) embracing midwife Donna Ockenden (right)on the release of the report into maternity services which released its findings today after a five year investigation which was delayed on multiple occasions

Rhiannon Davies (left) embracing midwife Donna Ockenden (right)on the release of the report into maternity services which released its findings today after a five year investigation which was delayed on multiple occasions 

Ms Ockenden (centre left) standing alongside the families of those whose loved ones died or suffered life changing injuries as result of poor Shrewsbury and Telford Hospital NHS Trust

Ms Ockenden (centre left) standing alongside the families of those whose loved ones died or suffered life changing injuries as result of poor Shrewsbury and Telford Hospital NHS Trust

Ms Ockenden (centre left) standing alongside the families of those whose loved ones died or suffered life changing injuries as result of poor Shrewsbury and Telford Hospital NHS Trust

Midwives’ missed chances to save baby Pippa from deadly infection 

Pippa Griffiths could still be alive today had midwives realised she was suffering a deadly infection

Pippa Griffiths could still be alive today had midwives realised she was suffering a deadly infection

Pippa Griffiths could still be alive today had midwives realised she was suffering a deadly infection

Pippa Griffiths could still be alive today had midwives realised she was suffering a deadly infection. The little girl was born at home in Shropshire in April 2016, but died just 31 hours later from a Group B Streptococcus infection.

A coroner ruled her death was avoidable and blamed a string of unforgivable errors by midwives.

The inquest heard medical staff missed a crucial opportunity to save Pippa when her mother Kayleigh rang a midwife with concerns about her baby’s feeding.

A second chance to save Pippa’s life was missed when her mother rang hours later to report bloody mucus, a sign of a serious bacterial infection which could have been treated with urgent hospital treatment.

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Mr Stanton, whose daughter Kate Stanton-Davies died shortly after being born under the trust’s watch in 2009, said: ‘SaTH was a horrendous case but they were not an isolated trust. 

‘You only have to look in East Kent and Nottingham where hundreds more families are coming forward to express concern about the care they received.’ 

His wife, Rhiannon Davies, gave birth in a midwife-led unit run by Shrewsbury trust which had no doctors. 

Ms Davies said she recalled ‘the midwives encouraged us to go there to ‘keep their numbers up’.’ 

Her pregnancy was wrongly classified as being low-risk and she should have given birth at a hospital where doctors could be on hand.

Kate Stanton-Davies was born ‘pale and floppy’ and died just a few hours after she was born. 

Ms Davies had suffered complications in the last month of her pregnancy due to a rare condition which means blood leaks from the foetus and into the mother.

An independent review – commissioned by NHS England following complaints lodged by the Davies family – found the original probe into Kate’s death was ‘poor’ and had ‘multiple inaccuracies’.   

Campaigning by Kate’s mother alongside another woman Mrs Griffiths, whose daughter Pippa also died as a result of inadequate care in 2016, led to Mr Hunt ordering the independent inquiry. 

Publishing its findings today, the inquiry found Shrewsbury and Telford Hospital NHS Trust presided over catastrophic failings for 20 years – and did not learn from its own inadequate investigations – which led to babies being stillborn, dying shortly after birth or being left severely brain damaged.

Mothers FORCED to have natural births  

Several mothers died after failings in care, while others were forced to have natural births despite the fact they should have been offered a C-section. 

Some babies suffered skull fractures, broken bones or developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries.

Mother said she’d lost fluid but was told she’d probably wet the bed… but had a stillbirth 

Charlotte Jackson raised concerns with staff that she had lost fluid and her baby's movement had reduced when she was 37 weeks pregnant

Charlotte Jackson raised concerns with staff that she had lost fluid and her baby's movement had reduced when she was 37 weeks pregnant

Charlotte Jackson raised concerns with staff that she had lost fluid and her baby’s movement had reduced when she was 37 weeks pregnant

Charlotte Jackson raised concerns with staff that she had lost fluid and her baby’s movement had reduced when she was 37 weeks pregnant.

Workers told her she had likely just wet herself, but he son – Jacob Harris – was was stillborn in November 2018 at Telford hospital.

The then 29-year-old from Bridgnorth got lawyers involved and the hospital trust admitted liability and agreed a settlement.

She told the Shropshire Star: ‘I was quite worried and upset. Jacob had always been a very active baby so when I noticed that his movements were reduced I had a gut feeling that something was not right.

‘However, I was shocked when I was told that it was a one off and I’d probably wet the bed.’

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A total of 29 incidents where babies suffered brain injuries were found as well as 65 cases where poor care resulted in cerebral palsy. 

The damning report examined cases involving 1,486 families, mostly covering 2000 to 2019, and reviewed 1,592 clinical incidents. 

It found there were ‘repeated errors in care which led to injury to either mothers or their babies’.

A review of 498 stillbirths found one in four had ‘significant or major concerns’ over the maternity care given, which, if managed appropriately, might, or would have, resulted in a different outcome.

There were also significant or major concerns in the care given to mothers in two thirds of cases where the baby had been deprived of oxygen during birth. 

Furthermore, nearly a third of neonatal deaths (fatalities within the first seven days of life) had ‘significant or major concerns’ over care which might have resulted in a different outcome.

The report said staff were ‘overly confident’ in their ability to manage complex pregnancies or where abnormalities were noted in pregnancy, and there was a reluctance to involve more senior staff.

There was also a culture of ‘them and us’ between midwives and obstetricians which meant some midwives were scared to involve consultants. 

In one example of shocking failure, detailed by Mr Javid today in the House of Commons, critical information regarding a patient was written on post-it notes which cleaners then swept into the bin. 

Mothers blamed for their OWN deaths 

The report also detailed how mothers themselves were frequently blamed for their own deaths.

In one incident in 2011 a husband was told his wife’s death had been due to her ‘size’.

‘[it was] difficult for the midwives to listen to baby’s heart beat due to her size,’ he was told. 

In another case, this time in 2002, trust documentation into the death of a mother noted: ‘She must have been responsible for some of that because she clearly did not complain very much and tended to ignore many of her symptoms.’ 

Ms Ockenden said: ‘Throughout our final report we have highlighted how failures in care were repeated from one incident to the next.’ 

‘In many cases, mother and babies were left with life-long conditions as a result of their care and treatment.

‘The reasons for these failures are clear. 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.

Midwife Donna Ockenden found that an obsession with natural births at Shrewsbury and Telford Hospital NHS Trust led to the deaths of 201 babies and left a hundred more with brain damage

Midwife Donna Ockenden found that an obsession with natural births at Shrewsbury and Telford Hospital NHS Trust led to the deaths of 201 babies and left a hundred more with brain damage

Midwife Donna Ockenden found that an obsession with natural births at Shrewsbury and Telford Hospital NHS Trust led to the deaths of 201 babies and left a hundred more with brain damage

Ms Ockenden paid tribute to the families of those who lost babies as a result of poor care at the trust, saying it would create a 'legacy of safety'

Ms Ockenden paid tribute to the families of those who lost babies as a result of poor care at the trust, saying it would create a 'legacy of safety'

Ms Ockenden paid tribute to the families of those who lost babies as a result of poor care at the trust, saying it would create a ‘legacy of safety’

Donna Ockenden claims families were still coming forward LAST YEAR about maternity safety issues at Shrewsbury trust

Donna Ockenden has claimed that families were still coming forward with concerns over Shrewsbury’s maternity service last year, even as the trust was under severe pressure to improve.

The senior midwife who led the investigation said her team looked at 1,592 clinical incidents involving mothers and babies at the trust over the two decades to 2019.

But speaking at a press conference today she warned families were getting in touch throughout 2020 and 2021 raising concerns over the care they received. 

She said: ‘Some of these recent families contacted us with reports they wanted to share with us. 

‘We haven’t been able to include them fully within the review but what we have seen is that the themes within their reports seem to echo concerns we have previously seen during this review.

‘Seeing these repeated themes is a cause for grave concern.

‘It is clear that there are a number of areas of maternity care where the Shrewsbury and Telford Hospital NHS Trust still has significant learning to undertake.’

Speaking about the report, she said ‘so many’ patients had repeatedly tried to raise concerns but were not listened to.

There were ‘repeated errors in care’, she said, ‘which led to injury to either mothers or to their babies’.

In the report, of the 12 cases of mothers who lost their lives giving birth at the trust, nine were cases with ‘significant or major concerns in the care provided’. 

‘Unfortunately, and overall, our report describes that a significant number of mothers and babies received care that fell way below the standards expected and this continued throughout the whole period of the review.’

Ms Ockenden added that there was evidence of ‘significant’ under-reporting of incidents in the trusts maternity unit, and there were cases that should have been investigated but were not. 

She said: ‘During the period this review looks at we are aware of eight external bodies who inspected, visited, assessed, or checked upon the trust.

‘This was a trust with significant problems and, while independent and external reports often indicated that the maternity service should improve its governance and investigatory procedures, this did not happen.

‘The trust was of the belief that its maternity services were good. They were wrong.’ 

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‘There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths.

‘What is astounding is that for more than two decades these issues have not been challenged internally and the trust was not held to account by external bodies.’

She added the inquiry highlighted the need for systematic change on a local and national level to ensure women and babies received professional and compassionate care.    

‘Going forward, there can be no excuses,’ she said.  

Ms Ockenden also claimed that families were still coming forward with concerns over Shrewsbury’s maternity service last year, even as the trust was under severe pressure to improve.

‘Some of these recent families contacted us with reports they wanted to share with us,’ she said.  

‘We haven’t been able to include them fully within the review but what we have seen is that the themes within their reports seem to echo concerns we have previously seen during this review.

‘Seeing these repeated themes is a cause for grave concern.’

She also said maternity care failures had been identified as far back as the 1970s with one family coming forward with a case from 1973. 

In releasing the report today Ms Ockenden praised Kate and Pippa’s families for their role in bringing poor care to light.

‘Kate’s and Pippa’s parents have shown an unrelenting commitment to ensuring their daughters’ short lives make a difference to the safety of maternity care,’ she said.

She added that the legacy of the report and its recommendations should be for a maternity service in England which is ‘appropriately funded, well-staffed, trained, motivated and compassionate and willing to learn from failings in care.’

Ex Health Secretary says scale of scandal is ‘beyond his darkest fears’

Former health secretary Jeremy Hunt, who originally ordered the inquiry , said the scale of the maternity scandal at Shrewsbury hospitals was ‘beyond his darkest fears’ with initial scope of the investigation concerning just 23 cases.

‘We have heard the same themes in maternity scandals again and again: an obsession with ‘normal birth’ that puts ideology above safety, and a toxic blame culture that forces staff to close ranks and attempt to silence bereaved families rather than openly learn from mistakes,’ he said. 

Mr Hunt, who now chairs the Health and Social Care Committee, said it was unbelievable the Government was not doing more to help mothers and babies safe in the wake of the Ms Ockenden’s report. 

‘It beggars belief that despite this urgent need for more doctors and midwives to deliver safe maternity care, later today the Government is set to reject an amendment to the Health and Care Bill that would permanently end the ongoing crisis in workforce numbers,’ he said.  

‘Many of the recommendations made by Donna Ockenden today are described as immediate and essential actions. 

‘It is therefore imperative that the Government acts urgently to give mothers confidence that measures are in place to give them a safe birth.’ 

Sajid Javid promises appalling failings won’t happen again 

Mr Javid told MPs in the House of Commons today that: ‘This report paints a tragic and harrowing picture of repeated failures in care over two decades, which led to unimaginable trauma for so many people rather than moments of joy and happiness.’ 

‘The cases in this report are stark and deeply upsetting. 

NHS bosses given 15 areas for ‘immediate and essential action’ 

The report recommended 15 areas for ‘immediate and essential’ action to improve maternity services across England. They are listed below: 

  1. All maternity units must receive ‘multi-year’ funding packages to ensure they can maintain minimum staffing levels, to be agreed nationally or locally. A portion of the budget must be ‘ring-fenced’ for training midwives;
  2. When maternity unit staffing levels fall below the ‘minimum’ level, senior management teams should be alerted immediately; 
  3. In cases where staff are concerned over expectant mother’s care, there should be a clear process for escalating this;
  4. All maternity services should be monitored by hospitals senior managers;
  5. When there is an ‘incident’ during a birth, such as the death of a baby, the resulting investigation must be ‘meaningful for families’ and staff must learn lessons in a ‘timely manner’; 
  6. When a mother dies during or after a birth, a postmortem must be carried out by a pathologist who is an expert in maternal physiology; 
  7. Midwives must train together, and regular compulsory training compulsory training should be offered; 
  8. Women with pre-existing medical problems such as heart disease and diabetes who are trying to get pregnant must have access to care. Women who are pregnant with twins or triplets must also receive specialist care; 
  9. All trusts must ensure systems are in place for women who are at a high risk of a pre-term birth; 
  10. When a woman chooses to give birth outside a hospital, midwives must give them ‘accurate’ advice on average transferral times to hospital units should this be required; 
  11. In cases where women suffer physical or mental harm during birth, treatments must be available;
  12. Women who are re-admitted to wards after birth must have a ‘timely’ consultant review; 
  13. Women who have suffered a loss during pregnancy must have access to ‘appropriate’ bereavement services; 
  14. All trusts must raise the number of neonatal critical care cots they have available; 
  15. The mental health and wellbeing of mothers, their partners and families as a whole must be ‘integral’ to maternity services. Midwives must engage with the community to ensure their services are what families say they need from care.
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‘This report is a devastating account of bedrooms that are empty, families that are bereft and loved ones taken before their time. We will act swiftly so that no families have to go through the same pain in the future.’

He added the Government will be accepting the report’s 84 recommendations in full and be working with the NHS regarding their implementation. 

‘The failures of care and compassion that are set out in this report have absolutely no place in the NHS,’ he said. 

Of these, 66 are for Shrewsbury and Telford Hospital NHS Trust, 15 for the wider NHS, and three for the Department of Health.  

Mr Javid also said the Government has already taken steps to invest in maternity services.

Last week, ministers announced they were investing £127million into growing the maternity workforce and improving neonatal care.  

He also outlined how a number of health professionals involved in the poor care of mothers and babies at the trust have now either been suspended or struck off.

Mr Javid insisted those responsible for poor care would be held to account.    

‘I know that Honourable Members and those families who have suffered would want reassurances that the individuals who are responsible for these serious and repeated failures will be held to account,’ he said. 

He also paid tribute to the families on their campaign for answers.

‘I cannot imagine how difficult it must have been for them to come forward and to tell their stories and this report is a testament to the courage and the fortitude that they have shown in the most harrowing of circumstances,’ he said. 

Some midwives have already been struck off or sanctioned by the professional regulator the Nursing and Midwifery Council (NMC).

One these was Claire Roberts, who was involved in the care of Pippa Griffiths.

Ms Roberts was struck off the NMC’s register just a few weeks ago.

Trust apologises for ‘pain and distress’ endured by victims 

Shrewsbury and Telford Hospital NHS Trust’s chief executive Louise Barnett, who came into the post in 2019, apologised for the pain and distress caused to families by failures.

‘Today’s report is deeply distressing, and we offer our wholehearted apologies for the pain and distress caused by our failings as a trust,’ she said.

‘We have a duty to ensure that the care we provide is safe, effective, high quality, and delivered always with the needs and choices of women and families at its heart.’

She added the trust had already implemented some of the changes from an earlier report from Ms Ockenden’s team and it will continue to make improvements.

The trust has already paid out more than £58million in clinical negligence damages and costs since 2000. 

Detective Chief Superintendent Damian Barratt, of West Mercia Police, said the investigation into the deaths at Shrewsbury was ongoing.   

‘We have been liaising closely with the Ockenden Review and are, of course, aware of the release of the report today,’ he said. 

Chief Executive for The Shrewsbury and Telford Hospital NHS Trust Louise Barnett ,who came into the post in 2019, apologised for the pain and distress caused to families by poor care

Chief Executive for The Shrewsbury and Telford Hospital NHS Trust Louise Barnett ,who came into the post in 2019, apologised for the pain and distress caused to families by poor care

Chief Executive for The Shrewsbury and Telford Hospital NHS Trust Louise Barnett ,who came into the post in 2019, apologised for the pain and distress caused to families by poor care

Ex Health Secretary says scale of scandal is ‘beyond his darkest fears’ 

Former health secretary Jeremy Hunt has said the scale of the maternity scandal at Shrewsbury hospitals was ‘beyond his darkest fears’.

Mr Hunt was the minster who ordered the independent inquiry back in 2017 when he was in charge of the Department of Health. 

Reacting to today’s publication of the report, he told the House of Commons the findings were ‘beyond my darkest fears’.

At the time Mr Hunt ordered the inquiry it was originally tasked to look at just 23 cases of poor care at the trust.

In comments made earlier he said the scale of the scandal at Shrewsbury and Telford NHS Trust was ‘shocking’.

He told BBC Radio 4’s Today programme: ‘I think it is important to say at the outset that the NHS facilitates the birth of nearly 600,000 babies every year and the vast majority are totally safe, and it’s getting safer.

‘But this report, from what I’ve been able to glean, I haven’t seen it myself, is very, very shocking and sobering reading.’

He said it was a ‘wake-up call’ into the need for the health service to deal with instances of poor care better.

Mr Hunt added: ‘Is it morally right that we need families to have to campaign over decades to get to the truth as to why their child died, rather than the NHS itself being really hungry to learn from mistakes, to put them to rights, to make sure that processes are changed so these tragedies don’t happen again?’

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‘Our investigation, named Operation Lincoln, was launched in 2017 to explore whether there is evidence to support a criminal case against the Trust or any individuals involved. This investigation remains ongoing and very much active.’

‘This is a highly complex and very sensitive investigation that has required us to speak to a large number of people to gather as much information as we can.’

He added that officers are consulting with medical specialists as part of the investigation but said no one has been charged as yet.  

‘No arrests have been made and no charges have been brought, however we are engaging with the Crown Prosecution Service as our inquiries continue,’ he said.

‘We will be fully reviewing the findings of the report and feeding appropriate elements into our investigation.’

Mr Barratt said the police do not underestimate the ongoing impact on the families involved as they wait for results of the investigation. 

‘Our thoughts remain with them, and we can reassure the community that when there is an update on our investigation we will share this with the families involved first and foremost and then to the wider public,’ he said. 

One of the mothers taking legal action against Shrewsbury and Telford NHS Trust is the Reverend Charlotte Cheshire, 44, from Newport, Shropshire. 

Her son Adam looked unwell after his birth in 2011, but her concerns were dismissed by staff at the trust, she alleges. 

After it was finally discovered that he had Group B Strep infection, he spent almost a month in intensive care.

Adam, now 11, has been left with multiple health problems. 

She said: ‘What I’m ultimately hoping is that all of the families get some answers.’

‘And then, in our individual cases, about how it’s possible for there to be such systemic failings over so many years, with seemingly either no-one noticing them, or potentially them being covered up.

‘So I’m hoping first of all for answers, but secondly, I’m hoping, as a result of Ockenden, there are genuine learnings.

‘Not the sort of, ‘oh, we’ll learn and get back to you’, but genuine learnings to improve maternity safety – primarily first of all at Shrewsbury and Telford, but secondly across the country as a whole.

Just ONE midwife has been struck off at scandal-hit NHS trust 

Parents Colin and Kayleigh Griffiths earlier this month welcomed the decision of a misconduct panel to strike of midwife whose failings contributed to the death of their one-day-old baby.

Claire Roberts, working at the scandal-hit Shrewsbury & Telford Hospital NHS Trust, failed to recognise their daughter Pippa’s need for urgent medical attention.

She effectively tried to cover up that failing in a late-night phone call with a colleague, the hearing ruled, and had not engaged with the disciplinary process.

Mrs Griffiths, from Myddle, Shropshire, said: ‘We think what was decided is fair given that one has clearly, very clearly, lied and been dishonest and is still a continued risk to patients.’ 

The Nursing & Midwifery Council said Roberts’ actions would be ‘regarded as deplorable by fellow practitioners’. 

Pippa’s mother, Kayleigh, had given birth at the family home in Myddle, near Shrewsbury, Shropshire, and had spoken with midwives to raise concerns that her daughter was not feeding and had brought up brown mucus.

The charges considered by the NMC related to two separate conversations midwives with Mrs Griffiths on April 27. 

The panel found Ms Roberts had effectively tried to cover up over her actions during a 2am call with Mrs Griffiths.

The latest stage of the hearing saw panel chair, David Evans, conclude that Roberts’ actions had amounted to misconduct, serious in some cases, and that her fitness to practise is impaired.

NMC solicitor Julian Norman said in light of the findings she requested that Roberts – who has not engaged with the process or attended any hearings – is struck off.

Mr Evans said the ‘only possible explanation’ for her actions over the inaccurate record of a conversation with Mrs Griffiths had been to ‘protect yourself from disciplinary action’.

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‘I don’t want any other family to have to go through what we’ve gone through.’ 

Reverand Cheshire added she was aware some might describe her a lucky as her son lived when so many others did not.  

‘But in a different way it’s changed my life forever, and it’s changed his – because he is hearing-impaired, visually impaired… and has violent, challenging behaviour,’ she said. 

‘Although he turned 11 on Friday, mentally he’s about four. The odds of that changing to a significant degree are highly unlikely. 

‘When he’s happy, when he’s calm, he’s gorgeous, he’s a delight and he’s wonderful, and all of the things you’d expect a mother to say. 

‘But when he’s overwhelmed, I wear the bruises.’ 

Julie Rowlings, whose daughter Olivia died after 23 hours of labour following a consultant’s use of forceps, said she wanted somebody from the trust to talk to her face to face about her case. 

‘I would like somebody from the trust to sit face to face with me, and talk to me. They’ve never done that,’ she said.  

‘They’ve apologised, via media, they’ve apologised to all the families via media, but they’ve never sat down with the families.

‘I want them to apologise face to face for what they put us through.

‘I’d like them to apologise for ignoring what we were trying to tell them at the time. It would go a long way.’

She added that with report’s publication she felt her daughter ‘finally had a voice’, adding that justice for the babies who died was coming.    

‘For every family out there, every family that’s come forward, this is for them.

‘Justice is coming. For every baby, justice is coming.’  

NHS England’s chief midwifery officer Jacqueline Dunkley-Bent and Matthew Jolly, the national clinical director for maternity and women’s health, said in a joint statement: ‘The findings of this important report highlight the clear failings endured by families when they should have been protected and cared for at the most special time in their lives; our thoughts are with all those who have been put through this devastation and we are sorry for the loss and the pain they have experienced.’  

NMC chief executive Andrea Sutcliffe welcomed the report’s findings, saying each case was tragedy. 

‘My heart goes out to all the women, babies and families whose lives have been so terribly impacted by these shocking failings in care,’ she said.

She said the NMC would continue to consider any referrals regarding midwives’ appropriately. 

‘Where referrals are made to us, we’ll always consider these carefully, taking account of the wider context when deciding the appropriate action to take in relation to individuals,’ she said.

MP reveals she was denied a cesarean due to ‘sexism’

An MP claims the NHS has a ‘systemic problem of sexism’, as she told the Commons about being denied a Cesarean.

Alicia Kearns, the Conservative MP for Rutland and Melton, said: ‘I’m afraid that as an MP I have concluded that NHS bureaucracy has a systemic problem of sexism.

‘I ask that he (Sajid Javid) keeps an eye on this nationally because I remember 36 hours in labour having already been rushed to the operating theatre being denied a C-section and then being rushed an hour later for a C-section only because my husband noticed that my son’s heart rate had plummeted to almost non-existent.

‘We must also prevent the unforgiveable and unscientific locking out of loved ones across all health services because that compromises care. It is still happening in hospitals around this country across different types of care.’

Mr Javid replied: ‘She’s absolutely right to emphasise this point that the NHS is there caring for everyone regardless of their gender.

‘But when it comes to women in particular, I hope she agrees with me this is precisely why the Government is right to want to set out, and we will do so shortly, a very detailed for the first time ever, a Women’s Health Strategy.’

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The Royal College of Paediatrics and Child Health (RCPCH) welcomed the report echoing calls for changes must be made to ensure no family suffers the same as the Shrewsbury victims. 

RCPCH registrar Steve Turner said: ‘As a College, our hearts go out to all the families involved, and while nothing can change the ordeal they faced, or bring back the loved ones they lost, we hope the report conveys the overwhelming need for change and improvements in care, so that no other families have to go through similar ordeals.’

He added the college will now be considering the report in full detail.  

NHS Providers deputy chief executive Saffron Cordery said the report must signal a turning point in maternity care in the health service.

‘As the report rightly highlights, one of the keys to delivering better outcomes for women and babies is developing the right culture – shifting from blame to one of learning and listening,’ she said.   

‘This would better encourage proactive approaches to safety and more open conversations, and bring a more patient centred approach to managing maternity care.’

She also highlighted how the report endorses an NHS Providers estimate that annual funding boost of between £200million and £350million is needed to address maternity staffing shortages. 

Shrewsbury and Telford Hospital NHS Trust is not alone in having its maternity services scrutinised, with reports expected from both Nottingham and East Kent.

An independent thematic review of maternity incidents, complaints and concerns is currently under way at Nottingham University Hospitals (NUH).

The review, looking at data from 2006, when the trust was formed, until mid October 2021, has been initiated for several reasons, but mainly due to families raising concerns about their cases, according to the review’s website.

It is expected to be completed by November 2022.

Meanwhile, an independent review into maternity and neonatal services at East Kent Hospitals University NHS Foundation Trust in the period since 2009 is also under way. 

Colin and Kayleigh Griffiths (left), Rhiannon Davies and Richard Stanton (right) with a copy of the Donna Ockenden Independent Review into Maternity Services today. Both families were left devastated by the death of their babies due to failings at Shrewsbury and Telford Hospital NHS Trust

Colin and Kayleigh Griffiths (left), Rhiannon Davies and Richard Stanton (right) with a copy of the Donna Ockenden Independent Review into Maternity Services today. Both families were left devastated by the death of their babies due to failings at Shrewsbury and Telford Hospital NHS Trust

Colin and Kayleigh Griffiths (left), Rhiannon Davies and Richard Stanton (right) with a copy of the Donna Ockenden Independent Review into Maternity Services today. Both families were left devastated by the death of their babies due to failings at Shrewsbury and Telford Hospital NHS Trust

Ex Health Secretary Jeremy Hunt says maternity scandal at Shrewsbury was 'worse' than he imagined after ordering the inquiry in 2017

Ex Health Secretary Jeremy Hunt says maternity scandal at Shrewsbury was 'worse' than he imagined after ordering the inquiry in 2017

Health secretary Sajid Javid said the report into the care failings were 'tragic and harrowing' and changes must be implemented to ensure such fallings never happen again.

Health secretary Sajid Javid said the report into the care failings were 'tragic and harrowing' and changes must be implemented to ensure such fallings never happen again.

Both former health secretary Jeremy Hunt (left) and Sajid Javid (right) have said care failings highlighted by a report into  at Shrewsbury and Telford Hospital NHS Trust must never happen again

Revealed: Shrewsbury maternity scandal was investigated in 2013… but local NHS bosses said services were SAFE 

Shrewsbury’s maternity services were first investigated in 2013, but found to be ‘safe’ and of ‘good quality’.

Shropshire Clinical Commissioning Group (CCG) and Telford and Wrekin CCG ordered the internal review following concerns over an ‘increased incidence of serious clinical adverse events’.

It covered the period from April 1, 2012, to March 31 the following year, including the period when an inquest ruled the death of baby Kate Stanton-Davies could have been avoided.

She was cold and floppy after being born and died six hours later. Mother Rhiannon warned in the days before the birth that her baby was moving less.

The report was completed by Dr Josh Dixey, then a secondary care consultant at Shropshire CCG.  

He concluded that the trust had a ‘maternity service to be proud of’ and that the service is ‘safe and effective’.

The report added: ‘There is a robust approach to risk management, clinical governance structures and learning from incidents which suggests a ‘learning organisation’.’

It also referred to the trust’s high level of ‘normal deliveries’ and lower than average rate of C-section— but described this as a ‘positive’.

At the unit, it noted the philosophy of care at the midwife-led unit was based on the view that pregnancy and birth were normal processes.

Many more babies died at the trust’s maternity unit after the report was completed.

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The review, which aims to complete its terms of reference by autumn 2022, is taking place following concerns raised about the quality and outcomes of maternity and neonatal care.

Last year East Kent Hospitals University NHS Foundation Trust was fined £733,000 over serious failures that led to the death of baby Harry Richford.

At the inquest into Harry’s death in January 2020, coroner Christopher Sutton-Mattocks listed a series of errors he found with the care given.

He gave a narrative conclusion that Harry’s death was contributed to by neglect and had been ‘wholly avoidable’. 

NHS bosses warn maternity staff shortage mean problems can never be fixed 

Health leaders have also warned that babies and mothers are still being put at risk in England over a shortage of midwives.

NHS and midwifery chiefs told the Guardian they fear that a growing shortage of maternity staff might mean trusts are unable to meet new standards set out in the wake of Ockenden report.

The number of midwives employed in the NHS in England has fallen to 26,901 according to figures published last month.

This is down from 27,272 a year ago, with the RCM warning it adds to an existing shortage of 2,000 staff.  

Royal College of Midwives (RCM) chief executive Gill Walton said: ‘I am deeply worried when senior staff are saying the cannot meet the recommendations of the Ockenden review which are vital to ensuring women and babies get the safest possible maternity care.’ 

Experts have warned the shortage of midwifery staff is being driven by a failure to attract new staff and existing midwives leaving the NHS due to being overworked.   

In her previous reports Ms Ockenden noted that Shrewsbury had been intent on keeping its C-section section rate low, with many women denied C-section or persuaded to have natural births – sometimes with catastrophic results.

But it wasn’t alone with other NHS trusts at the time also encouraging women to deliver their babies naturally and reduce the rate of C-sections.

In 2007, the RCM, the National Childbirth Trust and the Royal College of Obstetricians and Gynaecologists, signed a ‘normal birth consensus statement’. 

Among mothers taking legal action against Shrewsbury is the Reverend Charlotte Cheshire, 44, from Newport, Shropshire. Her son Adam looked unwell after his birth in 2011, but her concerns were dismissed by staff at the trust, she alleges

Among mothers taking legal action against Shrewsbury is the Reverend Charlotte Cheshire, 44, from Newport, Shropshire. Her son Adam looked unwell after his birth in 2011, but her concerns were dismissed by staff at the trust, she alleges

Among mothers taking legal action against Shrewsbury is the Reverend Charlotte Cheshire, 44, from Newport, Shropshire. Her son Adam looked unwell after his birth in 2011, but her concerns were dismissed by staff at the trust, she alleges

They said: ‘With appropriate care and support the majority of healthy women can give birth with a minimum of medical procedures…

‘Procedures used during labour which are known to increase the likelihood of medical interventions should be avoided where possible.’ 

Two years later, in 2017, the RCM dropped its ‘normal birth’ campaign and removed advice for midwives from its website.

The RCM removed its ‘top 10 tips for a normal birth’ and said the campaign would be dropped in favour of a better births plan.

For its part, the RCOG has recently apologised on Twitter for signing up to the ‘normal birth consensus statement’ in 2007.

It said this ‘may have mistakenly given the impression that targets around childbirth could take priority over safety. This is something we acknowledge and sincerely regret’. 

Shrewsbury and Telford Hospital NHS Trust serves nearly half a million people in Shropshire and consists of two hospitals, the Royal Shrewsbury and the Princess Royal in Telford, as well as a number of smaller community hospitals and maternity units.

Timeline: How the Shrewsbury maternity scandal unfolded 

2002

A parliamentary report highlights how Shrewsbury and Telford Hospital Trust (SaTH) has one of the lowest caesarean rates in country, at just 10 per cent of births.

2007

A leading number of maternity organisations sign a ‘normal birth consensus statement’ discouraging medical interventions like caesareans where possible.

At this time then health regulator, the Health Care Commission warns SaTH there were issues in how staff were monitoring foetal heart rates after incidents where babies were injured.

2009

Kate Stanton-Davies dies just hours after being born while under the care of Shrewsbury staff. Her parents begin to campaign for an investigation into what went wrong.

2013

Pictured: A file photo showing the entrance to the Royal Shrewsbury Hospital in Shropshire

Pictured: A file photo showing the entrance to the Royal Shrewsbury Hospital in Shropshire

Pictured: A file photo showing the entrance to the Royal Shrewsbury Hospital in Shropshire

Shrewsbury’s maternity services faced an internal investigation in 2013, but it concluded it was  ‘safe’ and of ‘good quality’.

2015

An inquiry into failings at Morecambe Bay NHS trust – where 11 babies and one mother suffered avoidable deaths – found a group of midwives’ overzealous pursuit of natural childbirth had ‘led at times to inappropriate and unsafe care’.

It said the entire NHS should learn from the failings observed.

2016

Pippa Griffiths dies shortly after being born while being cared for by Shrewsbury staff.

Her parents join forces with Kate Stanton-Davies’s mother and father in calling for an investigation into maternity services at the trust.

A birdseye view shows the sprawling Royal Shrewsbury Hospital in Shropshire on the outskirts of the town from above

A birdseye view shows the sprawling Royal Shrewsbury Hospital in Shropshire on the outskirts of the town from above

A birdseye view shows the sprawling Royal Shrewsbury Hospital in Shropshire on the outskirts of the town from above

2017

Then health secretary Jeremey Hunt orders an inquiry into the trust which will eventually be headed by midwife Donna Ockenden. The original scope of the inquiry encompasses just 23 cases. 

2018  

Former health secretary Matt Hancock said the Ockenden review is being expanded to include hundreds of cases.

Also in this year the trust is rated inadequate for safety by health watchdog the Care Quality Commission. 

2020

Pictured: A general view of The Princess Royal Hospital in Telford, Shropshire, which is also part of the scandal-hit trust

Pictured: A general view of The Princess Royal Hospital in Telford, Shropshire, which is also part of the scandal-hit trust

Pictured: A general view of The Princess Royal Hospital in Telford, Shropshire, which is also part of the scandal-hit trust 

Ms Ockenden announces the investigation is now looking at cases involving 1,862 families and releases early recommendations ahead of the full report.

2021

The inquiry findings are delayed to 22 March 2022 due to an influx of new information from Shrewsbury and Telford Hospital Trust. The final report was originally due in December 2021. 

2022  

The report is delayed again this time by a few weeks due to ‘parliamentary processes’. 

Today’s final report detailing the harrowing scale of deaths and injuries among babies and women over two decades of the trust’s care is published.

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The little girl whose deadly infection was ignored by midwives… just one of the hundreds of heart-breaking tragedies from the NHS maternity scandal that saw 201 babies and nine mothers lose their lives 

Devastated parents who lost children during the NHS’s worst ever maternity scandal have shared heartbreaking stories of the scandal at Shrewsbury and Telford Hospital NHS Trust that turned their lives upside down.

Mothers and fathers revealed how their sons and daughters were stillborn, left with skull fractures or brain injuries due to the incompetence of staff at the sites in Shropshire.

It comes as an independent inquiry into the scandal found some 201 babies and nine mothers could have – or would have – survived if they were provided with better care.

It presided over catastrophic failings for 20 years – and did not learn from its own inadequate investigations – which led to families leaving the hospitals without their newborn babies.

Some suffered skull fractures, broken bones or developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries.

Meanwhile several mothers were made to have natural births despite the fact they should have been offered a Caesarean. Here, the parents tell of their traumatic experiences:

Midwives’ missed chances to save baby Pippa from deadly infection:

Pippa Griffiths could still be alive today had midwives realised she was suffering a deadly infection. The little girl was born at home in Shropshire in April 2016, but died just 31 hours later from a Group B Streptococcus infection.

A coroner ruled her death was avoidable and blamed a string of unforgivable errors by midwives.

The inquest heard medical staff missed a crucial opportunity to save Pippa when her mother Kayleigh rang a midwife with concerns about her baby’s feeding.

A second chance to save Pippa’s life was missed when her mother rang hours later to report bloody mucus, a sign of a serious bacterial infection which could have been treated with urgent hospital treatment.

Mrs Griffiths wipes her eyes as she holds the Ockenden report at The Mercure Shrewsbury Albrighton Hotel in Shropshire

Mrs Griffiths wipes her eyes as she holds the Ockenden report at The Mercure Shrewsbury Albrighton Hotel in Shropshire

Mrs Griffiths wipes her eyes as she holds the Ockenden report at The Mercure Shrewsbury Albrighton Hotel in Shropshire

The couple (pictured with their baby) lost Pippa a day after she was born in 2016 due to midwives failing to spot the serious infection Group B Strep - even though Kayleigh warned them

The couple (pictured with their baby) lost Pippa a day after she was born in 2016 due to midwives failing to spot the serious infection Group B Strep - even though Kayleigh warned them

The couple (pictured with their baby) lost Pippa a day after she was born in 2016 due to midwives failing to spot the serious infection Group B Strep – even though Kayleigh warned them

Pippa was born at 8.34am and a midwife was supposed to have gone to the family home for a check-up later in the afternoon.

But the inquest heard she failed to turn up. Pippa developed a purple rash later that night and eventually stopped breathing. Emergency services managed to get her breathing again, but she later died.

The trust accepted that chances to save Pippa’s life were missed. Following the conclusion of the inquest, Mrs Griffiths said: ‘We’ve fought for her and fought for the truth and ultimately she could have been saved.’

Mother said she’d lost fluid but was told she’d probably wet the bed… but had a stillbirth

Charlotte Jackson raised concerns with staff that she had lost fluid and her baby’s movement had reduced when she was 37 weeks pregnant.

Workers told her she had likely just wet herself, but he son – Jacob Harris – was was stillborn in November 2018 at Telford hospital.

The then 29-year-old from Bridgnorth got lawyers involved and the hospital trust admitted liability and agreed a settlement.

She told the Shropshire Star: ‘I was quite worried and upset. Jacob had always been a very active baby so when I noticed that his movements were reduced I had a gut feeling that something was not right.

‘However, I was shocked when I was told that it was a one off and I’d probably wet the bed.’

She later added: ‘Giving birth to Jacob was absolutely horrific. It’s almost impossible to put into words the emotion of it all, knowing your baby had already died.’

Workers told her she had likely just wet herself, but he son - Jacob Harris - was was stillborn in November 2018 at Telford hospital. Pictured: The baby's grave

Workers told her she had likely just wet herself, but he son - Jacob Harris - was was stillborn in November 2018 at Telford hospital. Pictured: The baby's grave

Workers told her she had likely just wet herself, but he son – Jacob Harris – was was stillborn in November 2018 at Telford hospital. Pictured: The baby’s grave

 Reverend said her son looked unwell after being born – but was dismissed by staff:

The Rev Charlotte Cheshire, 44, from Newport, Shropshire, said her son Adam, now 11, looked unwell after his birth in 2011 but her concerns were dismissed by staff at the trust.

When it was finally discovered he had Group B Strep infection, he was rushed to intensive care where he stayed for almost a month.

Ms Cheshire, who is suing the trust, said her son has been left with multiple, severe health problems and should have received treatment much earlier.

Ms Cheshire, who is suing the trust, said her son has been left with multiple, severe health problems and should have received treatment much earlier for Adam (pictured)

Ms Cheshire, who is suing the trust, said her son has been left with multiple, severe health problems and should have received treatment much earlier for Adam (pictured)

Ms Cheshire, who is suing the trust, said her son has been left with multiple, severe health problems and should have received treatment much earlier for Adam (pictured)

The Rev Charlotte Cheshire, 44, from Newport, Shropshire, said her son Adam, now 11, looked unwell after his birth in 2011 but her concerns were dismissed by staff at the trust

The Rev Charlotte Cheshire, 44, from Newport, Shropshire, said her son Adam, now 11, looked unwell after his birth in 2011 but her concerns were dismissed by staff at the trust

The Rev Charlotte Cheshire, 44, from Newport, Shropshire, said her son Adam, now 11, looked unwell after his birth in 2011 but her concerns were dismissed by staff at the trust

She said: ‘What I’m ultimately hoping is that all of the families get some answers.

‘And then, in our individual cases, about how it’s possible for there to be such systemic failings over so many years, with seemingly either no-one noticing them, or potentially them being covered up.

‘So I’m hoping first of all for answers, but secondly, I’m hoping, as a result of Ockenden, there are genuine learnings.

‘Not the sort of, ‘oh, we’ll learn and get back to you’, but genuine learnings to improve maternity safety – primarily first of all at Shrewsbury and Telford, but secondly across the country as a whole.’

She added: ‘I don’t want any other family to have to go through what we’ve gone through.’

Jack Stephen Burn died 11 hours after being trapped in the birth canal for four minutes. His mother Hayley Matthews (pictured) had been told that nothing was wrong with her pregnancy but later found out that Jack had been distressed for 20 minutes before delivery

Jack Stephen Burn died 11 hours after being trapped in the birth canal for four minutes. His mother Hayley Matthews (pictured) had been told that nothing was wrong with her pregnancy but later found out that Jack had been distressed for 20 minutes before delivery

Jack Stephen Burn died 11 hours after being trapped in the birth canal for four minutes. His mother Hayley Matthews (pictured) had been told that nothing was wrong with her pregnancy but later found out that Jack had been distressed for 20 minutes before delivery

Baby boy died 11 hours after being trapped in birth canal for FOUR MINUTES:

Jack Stephen Burn died 11 hours after being trapped in the birth canal for four minutes.

His mother Hayley Matthews had been told nothing was wrong with her pregnancy but later found out Jack had been distressed for 20 minutes before delivery.

He had also contracted group B streptococcus, the lethal infection carried by one in five women.

Jack died in March 2015 at the Princess Royal Hospital in Telford, hours after another baby, Oliver Smale, died following similar complications. Oliver’s death was later deemed avoidable.

Although Jack’s death was not deemed avoidable, it was later considered part of the investigation.

Miss Matthews, from Chirbury, west Shropshire, previously said: ‘We would have both been in the hospital at the same time and there are so many parallels between the two cases.

‘As with this poor boy, Jack got his shoulder stuck during delivery.

‘They just left his head hanging while they went off to get someone to do something about it.’

A post mortem examination revealed that Jack had been starved of oxygen and had an infection on the lung and pneumonia caused by strep B.

Miss Matthews is campaigning for routine screening of strep B, which is not NHS policy. She said: ‘If I’d have been tested for strep B during my pregnancy they might have picked up on it and given me antibiotics at an earlier stage and this means that Jack might still be alive today.’

Jack Stephen Burn (pictured) died 11 hours after being trapped in the birth canal for four minutes

Jack Stephen Burn (pictured) died 11 hours after being trapped in the birth canal for four minutes

Jack Stephen Burn (pictured) died 11 hours after being trapped in the birth canal for four minutes

Rhiannon Davies had raised fears over reduced movement in the womb

Rhiannon Davies had raised fears over reduced movement in the womb

Rhiannon Davies had raised fears over reduced movement in the womb

Staff ignored mother’s warnings and said she was ‘low-risk’ despite daughter being born ‘pale and floppy’:

Kate Stanton-Davies died six hours after she was born because midwives failed to spot tell-tale signs of her deteriorating health.

Her mother Rhiannon Davies had raised fears over reduced movement in the womb, but was ignored by midwives who failed to properly monitor her pregnancy and wrongly deemed it low-risk.

Kate, who had anaemia, was born pale and floppy at Ludlow Community Hospital in Shropshire in March 2009. She was airlifted to Birmingham’s Heartlands Hospital but died.

A report published in February 2016 concluded her death was avoidable and identified a litany of failings and shoddy record-keeping at the Shrewsbury and Telford trust.

Two midwives were deemed responsible for the errors, which included changing Kate’s observation notes after her death.

Mrs Davies said: ‘You would think losing Kate would be the worst event in my life but the continual need to revisit the trauma of that day as we fight to get the truth means my distress is ongoing.

‘How many other baby deaths were avoidable, how many other investigations were not fit for purpose, how many other families have been betrayed, and how many other opportunities for learning have been lost?’

Kate Stanton-Davies died six hours after she was born because midwives failed to spot tell-tale signs of her deteriorating health

Kate Stanton-Davies died six hours after she was born because midwives failed to spot tell-tale signs of her deteriorating health

Kate Stanton-Davies died six hours after she was born because midwives failed to spot tell-tale signs of her deteriorating health

Katie Wilkins’ baby girl died at Shrewsbury Hospital after midwives left her in a side room for 48 hours and failed to properly monitor her. Miss Wilkins pictured with partner Dave Jackson, 45

Katie Wilkins’ baby girl died at Shrewsbury Hospital after midwives left her in a side room for 48 hours and failed to properly monitor her. Miss Wilkins pictured with partner Dave Jackson, 45

Katie Wilkins’ baby girl died at Shrewsbury Hospital after midwives left her in a side room for 48 hours and failed to properly monitor her. Miss Wilkins pictured with partner Dave Jackson, 45

‘My girl was still born after I was left in a side room’:

Katie Wilkins’ baby girl died at Shrewsbury Hospital after midwives left her in a side room for 48 hours and failed to properly monitor her.

Miss Wilkins was 15 days overdue when she arrived at the hospital to be induced in February 2013.

There were no beds available on the busy labour ward and Miss Wilkins, 24, claims she was ‘forgotten’ in the room for two days and visited by staff just a handful of times.

When a midwife did come to check on her progress they realised her baby’s heartbeat could not be found. Maddie was delivered stillborn in the early hours of the following day.

Hospital bosses later admitted the baby would have been born alive had they treated her in a more ‘timely’ manner.

Miss Wilkins said: ‘Maddie’s death was recorded as unexplained but we know why she died – because the midwives didn’t do their jobs properly.

‘I’d had a perfectly normal pregnancy and didn’t expect any problems with the birth. But I was left for hours at a time. The hospital was very busy and I felt like they simply forgot about me.

‘Giving birth to my stillborn daughter was heartbreaking. I should have been taking her home with me, but instead she had to stay at the hospital in a Moses basket. It was awful.’

Maddie was delivered stillborn in the early hours of February 21. The results of a post-mortem examination said the 6lbs 14oz baby girl’s death was unexplained.

In a letter to Miss Wilkins, Cathy Smith, head of midwifery at the hospital, apologised and admitted: ‘Had your induction occurred more timely, Maddison would likely to have been born alive.’ She added that practices at the hospital had now changed.

Miss Wilkins – who has since had a son and daughter with her partner Dave Jackson, 45, – is sceptical. She said: ‘We were told that changes would be made and women would be properly monitored, but now it seems that never happened. The hospital think they can say sorry and we should move on, but we can’t.’

Staff told her she was not suffering an abruption despite severe pains… when she was

Steph Hotchkiss from Telford started to suffer severe pains in September 2014 when she was nearly 31 weeks pregnant and asked if she was having an abruption.

Staff told her she was not, but they were wrong and baby Sophiya passed away just 32 hours later. Steph told the Shropshire Star she still suffers flashbacks of the trauma, caused by a ruptured placenta.

The then 28-year-old had similar issues when her son Kyan was born in 2013, and then had an emergency caesarian.

But she said staff refused to listen to her during her daughter’s birth, with her having told Royal Shrewsbury Hospital staff what she thought was happening.

She said: ‘I can’t put into words how painful this is for us. It was just so frustrating not to be listened to when I had previously had a difficult pregnancy involving a similar thing.’

Steph Hotchkiss from Telford started to suffer severe pains in September 2014 when she was nearly 31 weeks pregnant and asked if she was having an abruption

Steph Hotchkiss from Telford started to suffer severe pains in September 2014 when she was nearly 31 weeks pregnant and asked if she was having an abruption

Steph Hotchkiss from Telford started to suffer severe pains in September 2014 when she was nearly 31 weeks pregnant and asked if she was having an abruption

Encouraged to give birth naturally before baby got stuck and had to have emergency caesarean

Kamaljit Uppal was on the way to having her third child in 2003 but was told it would have to be delivered by caesarean because of how he was lying.

But staff at the Royal Shrewsbury Hospital encouraged her to give birth naturally and she went through 18 hours of labour.

The baby got stuck and Kamaljit had to have an emergency caesarean. She said: ‘I’m still coming out of my general anaesthetic and she said ‘he’s died’ and that’s it. They plonked the baby in my arms and said say goodbye.

‘I didn’t know how to say goodbye, I gave him a kiss and that was it. Once I came around a bit more they put me in a ward where there were babies.’    

Kamaljit Uppal was on the way to having her third child in 2003 but was told it would have to be delivered by caesarean because of how he was lying. Pictured: She still keeps the baby's unworn clothes

Kamaljit Uppal was on the way to having her third child in 2003 but was told it would have to be delivered by caesarean because of how he was lying. Pictured: She still keeps the baby's unworn clothes

Kamaljit Uppal was on the way to having her third child in 2003 but was told it would have to be delivered by caesarean because of how he was lying. Pictured: She still keeps the baby’s unworn clothes

Lost one of her twins during labour:

Debbie Greenaway lost one of her twin babies during labour at the trust and said the report ‘doesn’t change what’s happened for 20 years’.

She told This Morning: ‘To begin with, we thought it was just us, we had no idea until they started the report that exactly the same story has happened to so many people.

‘There were so many similarities… I wanted to tell my story and raise that awareness and give women a voice.’

‘Consultants came and went, there was no communication, I didn’t know what drugs I was being given or why, one consultant – I learnt afterwards was trying to take a foetal blood sample from John – which basically they cut his head to find his oxygen level, but they never explained what they were doing. I thought she was delivering them…

Debbie Greenaway lost one of her twin babies during labour at the trust and said the report 'doesn't change what's happened for 20 years'

Debbie Greenaway lost one of her twin babies during labour at the trust and said the report 'doesn't change what's happened for 20 years'

Debbie Greenaway lost one of her twin babies during labour at the trust and said the report ‘doesn’t change what’s happened for 20 years’

‘[At the start of my pregnancy] a c-section delivery was straight away brushed off with ‘we have the lowest caesarean rate in the country, we’re proud of it, there’s no reason for you not to have a natural birth’…’

She had an emergency caesarean, with Debbie saying, ‘When I woke up, all I remember was my husband handing me Daniel, I went, ‘Where’s John?’ and again, another doctor I’d never seen before said, ‘There’s nothing we can do, we need to turn the life support off’… and before I could react to that he walked off and came back carrying John.

‘And in my just come round state, I thought ‘Oh I got that wrong, he’s here, he’s fine’ and when he was handed to me I actually thought he was alive.’

Following a post mortem, she said: ‘All of the time frame was between me going in with two healthy babies with absolutely no issues and an awful long time from when he was brain damaged to delivery…’ 

We lost our only child at 4 days

Katie Anson’s son Kye died after just four days of life due to failures at the scandal-hit trust.

The baby was starved of oxygen in birth at Princess Royal Hospital, Telford, in 2015, but a coroner later heard he may have lived if staff had acted differently.

Miss Anson, 39, and partner Matthew Hall, 34, from the town, were unable to have another child due to unexplained infertility.

Katie Anson and her partner Matthew Hall

Katie Anson and her partner Matthew Hall

Katie Anson and her partner Matthew Hall

Kye died at New Cross Hospital in Wolverhampton. A 2016 inquest heard some heart rate recordings of the unborn baby had not been taken.

Shrewsbury coroner John Ellery said his death ‘could have been prevented’. The couple struggled to get pregnant for two years before Kye. They have just had their sixth failed attempt at IVF.

Miss Anson said: ‘To have had our only child taken away from us so tragically… makes it all the more difficult to swallow.’  

Bosses at shamed NHS trust who bagged lucrative new jobs in wake of scandal 

Simon Wright former CEO of Shrewbury Hospital (left) and Deidre Fowler former Director of Nursing (right)

Simon Wright former CEO of Shrewbury Hospital (left) and Deidre Fowler former Director of Nursing (right)

Simon Wright former NHS chief of Shrewbury Hospital (left) and Deidre Fowler former Director of Nursing (right)

At least four bosses at Shrewsbury and Telford Hospital walked into lucrative jobs in the wake of the maternity scandal.

Simon Wright, 54, left his £160,000 chief executive role in 2019 and was hired by a US healthcare firm handed millions in Government contracts.

Three other senior staff at the scandal-hit NHS hospital – including its former head of midwifery and director of nursing – were redeployed to other roles within the health service.

Mr Wright was hired as a ‘continuous improvement consultant’ by the Seattle-based Virginia Mason Institute, awarded a £12.5million contract by ministers in 2015.

Under the five-year scheme, the US hospital was asked to drive up standards at five trusts including Shrewsbury and Telford.

Cathy Smith the former Head of Midwifery at Shrewsbury Hospital

Cathy Smith the former Head of Midwifery at Shrewsbury Hospital

Cathy Smith the former Head of Midwifery at Shrewsbury Hospital

Deidre Fowler, former Director of Nursing at Shrewbury

Deidre Fowler, former Director of Nursing at Shrewbury

Shrewsbury and Telford’s medical director Edwin Borman

Shrewsbury and Telford’s medical director Edwin Borman

 Shrewsbury’s former director of nursing Deirdre Fowler, who was paid up to £125,000 a year, left in 2019 to join Bedford Hospitals NHS Trust as director of nursing and patient services. The trust’s medical director Edwin Borman took up a new role at the trust overseeing improvements to clinical practice

The trust’s former head of midwifery, Cathy Smith, also landed a role at Shrewsbury which involves liaising with the hospital in Seattle.

She was criticised for having a ‘defensive attitude’ and being unwilling to learn from mistakes made by the trust.

But despite receiving a final written warning she was given the new job by the hospital.

Shrewsbury’s former director of nursing Deirdre Fowler, who was paid up to £125,000 a year, left in 2019 to join Bedford Hospitals NHS Trust as director of nursing and patient services.

And Shrewsbury and Telford’s medical director Edwin Borman – who claimed in 2017 that baby death rates were no worse than anywhere else when they were up to 46 per cent higher in some categories – took up a new role at the trust overseeing improvements to clinical practice. 

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Source: dailymail

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