The author of a report into Britain’s worst maternity scandal said pregnant women will not be safe to give birth until her full raft of recommendations are implemented.

Healthcare expert Donna Ockenden said it was ‘astounding’ that ‘systemic’ failings at Shrewsbury and Telford Hospital NHS Trust happened for so long.

She added ‘maternity services cannot provide safe and effective care’ without a new ‘blueprint’ for care for mothers and babies and proposed 15 ‘immediate and essential’ steps for every NHS maternity ward to take, including better training and better communication with families.

The report also said an obsession with ‘normal births’ contributed to the biggest maternity scandal in NHS history. 

Ockenden blamed eight external bodies in part for allowing the litany of errors that resulted in 201 babies and nine mothers dying in avoidable circumstances.

Rhiannon Davies (left) embraces Kayleigh Griffiths, following the release of the final report by Donna Ockenden, chair of the Independent Review into Maternity Services at the Shrewsbury and Telford Hospital NHS Trust

Rhiannon Davies (left) embraces Kayleigh Griffiths, following the release of the final report by Donna Ockenden, chair of the Independent Review into Maternity Services at the Shrewsbury and Telford Hospital NHS Trust

Rhiannon Davies (left) embraces Kayleigh Griffiths, following the release of the final report by Donna Ockenden, chair of the Independent Review into Maternity Services at the Shrewsbury and Telford Hospital NHS Trust

Ann Reeves (right,) the daughter of Elsie Devine who died at Gosport War Memorial Hospital

Ann Reeves (right,) the daughter of Elsie Devine who died at Gosport War Memorial Hospital

Ann Reeves (right,) the daughter of Elsie Devine who died at Gosport War Memorial Hospital

Donna Ockenden, chair of the Independent Review into Maternity Services at the Shrewsbury and Telford Hospital NHS Trust, presented her devastating report yesterday

Donna Ockenden, chair of the Independent Review into Maternity Services at the Shrewsbury and Telford Hospital NHS Trust, presented her devastating report yesterday

Donna Ockenden, chair of the Independent Review into Maternity Services at the Shrewsbury and Telford Hospital NHS Trust, presented her devastating report yesterday

In one case the Care Quality Commission, which regulates the NHS in England, had even rated the maternity ward at the Trust as ‘good’.

Ockenden’s report uncovered 1,592 times that women and their babies died or were left disabled or traumatised by their experiences at the Trust.

She said the Trust had come ‘to blame mothers… even for their own deaths’. 

The devastating report said some women were forced to have vaginal births when they should have been offered a caesarean – all because natural birth zealots wanted to keep surgery rates low.  

The landmark 250-page report found the trust presided over catastrophic failings for 20 years, ignored the concerns of parents and did not learn from its own inadequate investigations. 

This led to babies being stillborn, dying shortly after birth or being left severely brain damaged.

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

The inquiry’s chairman, maternity expert Donna Ockenden, examined cases involving 1,486 families from 1973 to 2020 and reviewed 1,592 incidents. 

She warned that staff were still expressing concerns about the trust – and issued 15 ‘immediate’ actions for all maternity services in England amid fears of similar failings elsewhere.

Bereaved mothers Rhiannon Davies and Kayleigh Griffiths, who spearheaded calls for the inquiry after their daughters’ deaths, hugged as they welcomed the findings.

But Mrs Griffiths, whose daughter Pippa died avoidably in 2016, said: ‘This is 200-odd pages of harmed families. It’s a disgrace that they haven’t learned when we’ve told them what the issues were.’

Rhiannon Davies of Ludlow Shropshire pictured with her daughter Kate just moments after her birth on Sunday March 1, 2009

Rhiannon Davies of Ludlow Shropshire pictured with her daughter Kate just moments after her birth on Sunday March 1, 2009

Rhiannon Davies of Ludlow Shropshire pictured with her daughter Kate just moments after her birth on Sunday March 1, 2009

Richard Stanton and Rhiannon Davies, pictured at their home in Hereford, Herefordshire. Rhiannon is holding Kate's teddy bear - a gift for their daughter Kate who passed away at just 6hrs of age. Her death was later found to have been avoidable

Richard Stanton and Rhiannon Davies, pictured at their home in Hereford, Herefordshire. Rhiannon is holding Kate's teddy bear - a gift for their daughter Kate who passed away at just 6hrs of age. Her death was later found to have been avoidable

Richard Stanton and Rhiannon Davies, pictured at their home in Hereford, Herefordshire. Rhiannon is holding Kate’s teddy bear – a gift for their daughter Kate who passed away at just 6hrs of age. Her death was later found to have been avoidable

Richard Stanton and Rhiannon Davies often wonder what kind of girl their firstborn, Kate, would have grown up to become.

‘She would have been 13 on March 1 and you think, ‘What clothes would Kate be wearing today? What music would she like?’ says Richard, 52, a photographer in Hereford.

‘All our lives would have been drastically different if Kate was alive. She should be here today because her death was completely avoidable.’

Kate died in her father’s arms just six hours after she was born at a mid-wife-led unit in Ludlow, Shropshire.

Katie Wilkins, 26, had a still born baby girl, Maddison, in Feb 2013 at Royal Shrewsbury Hospital

Katie Wilkins, 26, had a still born baby girl, Maddison, in Feb 2013 at Royal Shrewsbury Hospital

Katie Wilkins, 26, had a still born baby girl, Maddison, in Feb 2013 at Royal Shrewsbury Hospital

Since that day in 2009, Richard and Rhiannon, 47, have fought tirelessly to expose what Richard describes as the trust’s ‘abhorrently poor care’.

He believes the trust’s obsession with natural birth impacted his wife’s care and says she should never have been near a midwife-led unit.

‘As parents, we were ignored, fobbed off, treated like we were the problem – just noisy people with an axe to grind,’ he says.

‘You never get over the loss of a child. You only learn to live with it.’

The report found that:

  • One in four of the 498 stillbirths reviewed had ‘significant or major concerns’ over the maternity care given;
  • There were 29 cases where babies suffered severe brain injuries and 65 cases of cerebral palsy;
  • Twelve deaths of mothers were investigated, none of whom received care in line with best practice at the time;
  • Some women were blamed for their own deaths, while incidents that should have triggered a serious incident investigation were ‘inappropriately downgraded’;
  • Midwifery staff were ‘overly confident’ in their abilities, and there was a reluctance to involve more senior staff;
  • Families were locked out of reviews when things went wrong and were often treated without compassion;
  • The trust repeatedly failed to adequately monitor babies’ heart rates, with catastrophic results, and did not use drugs properly during labour;
  • Leaders and midwives were determined to keep caesarean section rates low – consistently 8 per cent to 12 per cent below national averages;
  • There were ‘significant staffing and training gaps’ and ‘medical staff rotas have been overstretched throughout’;
  • One staffer described the department as the ‘Republic of Maternity’ and suggested it did not like being overseen by management.

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

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

But there were no beds available on the labour ward and instead, Miss Wilkins claims, she was ‘forgotten’ in a side room for more than two days and visited by staff just a handful of times. When a midwife did come to check, they realised her baby’s heartbeat could not be found.

Even then midwife Heather Lort failed to call a doctor and instead told Miss Wilkins to ‘go for a walk’.

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

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

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

Colin and Kayleigh Griffiths, 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

Colin and Kayleigh Griffiths, 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

Colin and Kayleigh Griffiths, 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

Chelsey Campbell, Carley McKee, Colin Griffiths, Fiona Carr, Charlotte Cheshire, Rhiannon Davies, Richard Stanton, Kayleigh Griffiths, Donna Ockenden, Nicky Lauder, David Boylett, Hayley Matthews, Steph Hotchkiss, Julie Rawlings, Neil Rawlings and Sonia Leigh stand with the final Ockenden report

Chelsey Campbell, Carley McKee, Colin Griffiths, Fiona Carr, Charlotte Cheshire, Rhiannon Davies, Richard Stanton, Kayleigh Griffiths, Donna Ockenden, Nicky Lauder, David Boylett, Hayley Matthews, Steph Hotchkiss, Julie Rawlings, Neil Rawlings and Sonia Leigh stand with the final Ockenden report

Chelsey Campbell, Carley McKee, Colin Griffiths, Fiona Carr, Charlotte Cheshire, Rhiannon Davies, Richard Stanton, Kayleigh Griffiths, Donna Ockenden, Nicky Lauder, David Boylett, Hayley Matthews, Steph Hotchkiss, Julie Rawlings, Neil Rawlings and Sonia Leigh stand with the final Ockenden report

Maddison was delivered stillborn the following day, weighing 6lb 14oz. Lort is one of just two midwives found guilty of misconduct and banned from practising. 

Last night Miss Wilkins, 26, a carer from Newtown in Powys, said: ‘Hopefully, the Ockenden report will be the first step towards getting justice for Maddison. The hospital admitted they failed us.’

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 have been born alive.’

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

Katie Anson and Matthew Hall are desperate to start a family, five years after their only son Kye died

Katie Anson and Matthew Hall are desperate to start a family, five years after their only son Kye died

Katie Anson and Matthew Hall are desperate to start a family, five years after their only son Kye died

Kye (pictured) was starved of oxygen during a difficult birth. An inquest subsequently found his death could have been prevented

Kye (pictured) was starved of oxygen during a difficult birth. An inquest subsequently found his death could have been prevented

Kye (pictured) was starved of oxygen during a difficult birth. An inquest subsequently found his death could have been prevented

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.

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.’

Sajid Javid last night ordered hospitals to involve mothers in decisions about labour, adding: ‘The only normal birth is a safe birth.’ 

The Health Secretary said the staff responsible for the scandal would be ‘held to account’ and revealed that police were probing around 600 cases.

Mr Javid yesterday apologised to the families who had suffered ‘unimaginable trauma’ and said the Government accepted the report’s findings in full. 

He said some members of staff had been suspended or struck off, while members of senior management ‘have been removed from their posts’.

‘It is right that both the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives have said recently that they regret their campaign for so-called ‘normal births’,’ he added.

‘It is vital that across maternity services we focus on safe and personalised care where the voice of the mother is heard throughout.’

Tory MP Jeremy Hunt, who commissioned the Ockenden Review as health secretary in 2017, admitted its findings ‘go beyond my darkest fears’.

Previous reports into maternity services in Shrewsbury either gave a glowing picture of safe care or called for improvements that were never made.

Mr Javid yesterday apologised to the families who had suffered 'unimaginable trauma' and said the Government accepted the report's findings in full

Mr Javid yesterday apologised to the families who had suffered 'unimaginable trauma' and said the Government accepted the report's findings in full

Mr Javid yesterday apologised to the families who had suffered ‘unimaginable trauma’ and said the Government accepted the report’s findings in full

Tory MP Jeremy Hunt, who commissioned the Ockenden Review as health secretary in 2017, admitted its findings 'go beyond my darkest fears'

Tory MP Jeremy Hunt, who commissioned the Ockenden Review as health secretary in 2017, admitted its findings 'go beyond my darkest fears'

Tory MP Jeremy Hunt, who commissioned the Ockenden Review as health secretary in 2017, admitted its findings ‘go beyond my darkest fears’ 

The chief executive of the trust said that she was confident its services were now safe for families.

Louise Barnett said the organisation was getting the support it needed to make further improvements, adding: ‘I would like to apologise fully to the families involved for the poor care at this trust.’

Independent reviews of maternity services are also under way at Nottingham University Hospitals and East Kent Hospitals University Foundation Trust. 

Britain’s worst maternity scandal: The key findings 

  • The inquiry, which examined cases involving 1,486 families mostly from 2000 to 2019, found ‘repeated errors in care’ which led to injury to mothers and babies
  • The deaths of 201 babies and nine mothers could, or would, have been prevented if the trust had provided better care
  • Some women were blamed for their own deaths or for the deaths of their babies
  • Mothers and babies were harmed by the trust’s obsession with ‘normal births’ and its failure to conduct more caesareans
  • Midwives were ‘overly confident’ in their own abilities and there was a reluctance to involve more senior staff
  • Previous reports into maternity services at the trust either gave a glowing picture of safe care or suggested improvements that were never made
  • Staff were frightened to speak out about failings amid ‘a culture of undermining and bullying’
  • Employees claimed they were advised by managers not to speak to the inquiry about what had gone wrong at the trust
  • The review team identified 15 ‘immediate and essential actions’ which must be implemented by all trusts in England providing maternity services, including improved funding, safe staffing levels, learning from deaths of mothers and better support for families
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Source: Daily Mail

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