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

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 an independent inquiry into the scandal found some 201 babies and nine mothers could have – or would have – survived if the trust had provided 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.

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:

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

They ignored my warnings and said I was ‘low-risk’:

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?’

Midwives’ missed chances to save Pippa:

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 unforgiveable 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.

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

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

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.’

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.’

Mother 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 that 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.

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

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. 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 that nothing was wrong with her pregnancy but later found out that 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 and is one of dozens being probed. Although Jack’s death was not deemed avoidable, it is now being considered as 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.’ 

201 babies and nine mothers died in biggest ever NHS maternity scandal: Damning five-year inquiry into Shrewsbury trust – where women were blamed for their OWN deaths – uncovers two decades of repeated failures as victims demand justice

Devastated families whose babies died or were left brain dead during the country’s worst ever maternity scandal have said a damning report on the NHS‘s failings was a ‘bittersweet’ victory.

Mothers and fathers whose children passed away shortly after being born at Shrewsbury and Telford Hospital NHS Trust said the findings were ‘really difficult to comprehend’.

Some of them added they hope the police now have enough evidence to prosecute the medical staff responsible for the hundreds of deaths up until 2019.

Key points from the damning inquiry into the hospital trust:

Here are the main points from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust:

  • 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 could have – or would have – survived if the trust had provided better care.
  • Most of the neonatal deaths occurred in the first seven days of life, with nearly a third of all incidents reviewed (27.9%) identified as having significant or major concerns in the maternity care which might or would have resulted in a different outcome.
  • 498 cases of stillbirth were reviewed and graded, and one in four cases were found to have significant or major concerns in care which if managed appropriately might, or would have, resulted in a different outcome.
  • There were 12 maternal deaths reviewed and in nine of the 12 cases (75%) the review team identified significant or major concerns in the care received.
  • Ms Ockenden said staff were frightened to speak out about failings amid ‘a culture of undermining and bullying’.
  • Staff also claimed they were advised by trust managers not to take part in a ‘staff voices’ initiative set up to assist the investigation into what went wrong, according to Ms Ockenden.
  • The review team identified 15 ‘immediate and essential actions which must be implemented by all trusts in England providing maternity services’.
  • These include matters such as workforce funding, planning and sustainability, safe staffing, escalation and accountability, leadership, investigations of incidents and complaint handling, learning from the deaths of mothers, multidisciplinary training, complex antenatal care, pre-term, labour and birth at term, obstetric anaesthesia, post-natal care, bereavement care, neonatal care and supporting families.
  • 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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Some 201 babies and nine mothers could have – or would have – survived if an NHS trust had provided better care, the independent inquiry into the UK’s biggest maternity scandal has found.

Shrewsbury and Telford Hospital NHS Trust saw 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 brain damaged.

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.

Several mothers were made to have natural births despite the fact they should have been offered a Caesarean, the report concluded.

Shrewsbury and Telford Hospital NHS Trust’s chief executive Louise Barnett today apologised for the pain and affected families had endured.

The victims’ families gave mixed reactions as they responded to the shocking findings, with some calling for police to launch prosecutions.

Kayleigh Griffiths said: ‘It’s really difficult to comprehend.’ Her partner Colin Griffiths added: ‘It’s bittersweet. It’s an accomplishment, but it didn’t need to happen.

‘It shouldn’t have happened in the first place.’ Kayleigh added: ‘We visited Pippa this morning before we came, and we said ‘this is what we’ve done for her’.

‘It’s just heartbreaking. There’s so many stories, so many families here today.’ Colin said: ‘Everyone’s come together for this result.’

The couple 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.

Mrs Griffiths added: ‘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.

‘It’s really important, and it’s really important that maternity services up and down the country read this and listen to what families have gone through and the impact that’s had on people’s lives.’

Meanwhile Richard Stanton, whose daughter Kate Stanton-Davies died after just six hours in 2009, called for police to launch prosecutions against those responsible.

He said on Tuesday morning: ‘I hope the police will now have sufficient evidence to present to the CPS for a prosecution.’

Julie Rowlings, whose daughter Olivia died after 23 hours of labour following a consultant’s use of forceps, said she wanted somebody from Shrewsbury and Telford Hospital NHS Trust to talk to her face to face about her case.

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 

Colin and Kayleigh Griffiths, Rhiannon Davies and Richard Stanton are pictured with a copy of the Donna Ockenden Independent Review today

Colin and Kayleigh Griffiths, Rhiannon Davies and Richard Stanton are pictured with a copy of the Donna Ockenden Independent Review today

Colin and Kayleigh Griffiths, Rhiannon Davies and Richard Stanton are pictured with a copy of the Donna Ockenden Independent Review today

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

The Shropshire baby deaths: The harrowing stories that informed the inquiry

Investigator Donna Ockenden’s team has recorded the harrowing stories of children and mothers dying at the hands of the Shrewsbury and Telford Hospital NHS Trust. In some cases, women were blamed for losing their babies, while others had their concerns and complaints dismissed, compounding their grief at losing a child.

Families were often treated unkindly – echoed in women’s medical records, in documents provided to the inquiry by the trust and families, and in letters sent to families by the trust. In her interim report in December 2020, Ms Ockenden described how, in 2011, a woman was in agony but was told that it was ‘nothing’, while staff were dismissive and made her feel ‘pathetic’. One obstetrician was abrupt and called her ‘lazy’. In a 2013 case investigated by the inquiry, a woman was left in great pain after delivery and screamed for hours before staff intervened. In 2009, despite a woman having known risk factors, her care was not escalated to more senior staff, and errors were made in monitoring the baby during labour.

Even after birth, the baby was not monitored despite clear warning signs, and was transferred, too late, to a specialist unit where it died. Other cases recorded by Ms Ockenden’s team are equally distressing, with one baby dying in 2016 after the mother was not adequately monitored due to the unit being ‘busy’. In this case, the baby was delivered in a very poor condition having suffered a brain injury due to inappropriate care. Then in 2017, a woman suffered a catastrophic haemorrhage and later died.

Her family stated that there had not been an explanation of the risks of birth in the midwifery-led unit, nor information on the need for transfer if complications arose. In 2011, a new mother died after delays treating her severe high blood pressure. Following delivery, there was a further delay in seeking senior clinical advice. She subsequently died in another hospital. In one 2016 case a pregnant woman with known large uterine fibroids was not referred to an obstetrician as she should have been. Errors were made in recording the baby’s growth and it died on the day of birth from a severe hypoxic (low oxygen) birth injury.

Another baby died in 2006 after the mother was given oxytocin in labour, despite it not being recommended for a breech baby. This baby was born in very poor condition and died a few days later. Ms Ockenden’s review further noted there were cases where women were given drugs inappropriately despite abnormal scans. As a result, some babies were born with brain injury, cerebral palsy, or were stillborn or died soon after. In other errors, midwives recorded the mother’s heart rate instead of the baby’s, with serious consequences and one baby death. This was as recently as 2015.

Also in 2015, despite a mother requesting a Caesarean following a previous one, her request was denied. After a complicated natural birth, the baby died a few days later from hypoxic brain injury and complications of shoulder dystocia (where the baby’s head is born but one of the shoulders becomes stuck). A subsequent investigation failed to acknowledge omissions in care. Ms Ockenden’s reports have said there were many opportunities to learn from incidents, but these did not happen.

In 2015, a woman in labour at the midwife-led birth centre was not adequately monitored. When problems were eventually identified in labour there was a delay in transferring her to the labour ward, where her baby was delivered in very poor condition and suffered brain damage. The baby subsequently died. The review team also found evidence of repeated attempts at vaginal delivery with forceps, sometimes using excessive force. It said there was clear evidence that obstetricians were not following established local or national guidelines for safe deliveries of this type.

In one case, in 2007, repeated attempts at forceps delivery left a baby with multiple skull fractures. It subsequently died. In another case, a woman known to have a big baby was refused her request for a Caesarean. She had a forceps delivery and the baby suffered a fracture. One baby in 2017 died following a traumatic forceps delivery by two doctors, while another woman had repeated attempted forceps delivery, leading to the baby having skull fractures and developing cerebral palsy.

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

‘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.’

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 that 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.

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.

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

The damning report, led by maternity expert Donna Ockenden, examined cases involving 1,486 families, mostly from 2000 to 2019, and reviewed 1,592 clinical incidents.

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.

Some 40 per cent of these stillbirths were never investigated by the trust. There were also ‘major’ concerns over the care given to mothers in two-thirds of cases where the baby had been deprived of oxygen during birth.

Overall, there were also 29 recorded cases where babies suffered severe brain injuries and 65 cases of cerebral palsy.

Furthermore, nearly a third of neonatal deaths had ‘significant or major concerns’ over care. Yet the trust had only looked at 43 per cent of these.

Overall, 12 deaths of mothers were investigated, none of whom received care in line with best practice at the time. In three-quarters of these cases, care ‘could have been significantly improved’.

Some women were blamed for their own deaths, the report found, while incidents that should have triggered a serious incident investigation were ‘inappropriately downgraded’ by the trust to its own series of ‘high risk’ case reviews, which were ‘apparently to avoid external scrutiny’.

Ms Ockenden’s report said this ‘meant that the true scale of serious incidents within maternity services at the trust went unknown over a long period of time’.

But she added there were still ‘persistent failings in incident investigations as late as 2018-2019’. The report said midwifery staff were ‘overly confident’ in their abilities, 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.

Ms Ockenden’s team found families were locked out of reviews when things went wrong and were often treated without compassion and kindness.

The trust, which is currently ranked inadequate, was also found to have repeatedly failed to adequately monitor babies’ heart rates, with catastrophic results, alongside not using drugs properly in labour.

 

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 

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

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 caesareans — 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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Leaders and midwives were determined to keep Caesarean section rates low – consistently 8 per cent to 12 per cent below the English average – despite the fact this repeatedly had severe consequences.

Ms Ockenden noted the leadership ‘up to board level’ at the trust was in a constant state of ‘churn and change’.

She said the trust was focused on other clinical areas and there was ‘significant turnover’ at board and management level, which meant maternity issues remained ‘largely unseen’.

In a briefing, Ms Ockenden said the review team found evidence of ‘significant’ under-reporting of harm and a prevailing belief services were safe, despite the fact eight external bodies ‘inspected, visited, assessed, or checked upon the trust’.

Ms Ockenden said ‘so many parents’ had tried to raise concerns but were not listened to.

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.’

Tory MP Jeremy Hunt, who ordered the inquiry in 2017 when he was health secretary, said the numbers are ‘worse’ than he could have imagined and he hopes the report will be ‘a wake-up call’.

Mr Stanton and Rhiannon Davies, who have campaigned for years over the poor care, lost their daughter Kate hours after her birth in March 2009.

The trust noted her death but described it as a ‘no harm’ event, although an inquest jury later ruled Kate’s death could have been avoided. The trust still insisted its care had been in line with national guidelines.

In her report, Ms Ockenden said there was evidence of poor investigation of three baby deaths in similar circumstances (Kate Stanton-Davies and babies Joshua and Thomas) within the same year.

She said there was a lack of transparency and a ‘lost opportunity’ to prevent further baby deaths occurring.

Ms Ockenden also pointed to ‘significant staffing and training gaps’, while ‘medical staff rotas have been overstretched throughout’.

One employee described the maternity service as the ‘Republic of Maternity, where, often, the maternity service seemed to consume its own smoke, and didn’t like having oversight by the corporate team’.

Another couple who have led the campaign for safer care are Mr and Mrs Griffiths, whose daughter Pippa died in 2016 from a Group B Strep infection. A year later, a coroner ruled her death could have been avoided.

A criminal investigation into what happened at the trust is being carried out by West Mercia Police.

Louise Barnett, chief executive at the trust, said improvements have been made and are continuing, adding: ‘Today’s report is deeply distressing and we offer our wholehearted apologies for the pain and distress caused by our failings as a trust.’ 

Source: dailymail

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