Back in 2018, the Daily Mail published a front page investigation under the headline: ‘New Maternity Deaths Scandal.’
Our report revealed how more than 60 babies and mothers were feared to have died or suffered devastating harm at the Shrewsbury and Telford Hospital NHS Trust (SATH).
The response from the then chief executive Simon Wright could not have been more aggressive or critical.
We were ‘irresponsible,’ he said. We were ‘scaremongering,’ he said. What we had printed was ‘untrue,’ he said.
His ‘statement’ was issued in a press release rubbishing our report, the first expose of the emerging tragedy, and repeated in a letter which accused the paper of causing ‘unnecessary anxiety among women going through one of the most important times of their life’.
The front page investigation ‘New Maternity Deaths Scandal.’ in 2018
There were ‘no signs of failure of care,’ in 23 of 31 legacy cases, the letter stressed.
Could there be a more damning indictment of the culture of obfuscation at the Shrewsbury and Telford NHS Trust?
The initial, interim findings of the independent inquiry into 250 of the 1,862 family complaints have pointed to catastrophic failings at the authority.
The report published yesterday by midwife Donna Ockenden identified hundreds of cases of potentially sub-standard care which contributed to the deaths of more than a dozen women and babies in what is believed to be the NHS’s worst ever maternity scandal.
But that is not the whole story.
Ockenden found that mothers had been subjected to a lack of kindness and compassion by staff, with some parents being blamed for what happened to their babies, while incidents of poor care were not properly investigated.
She does not actually use the word ‘cover-up’ but former health secretary Jeremy Hunt, who set up the review in 2017, is in no doubt.
‘There is nothing more cruel in life than losing a child – but to do so because of mistakes that were covered up makes things infinitely more painful,’ he said.
Families who were ‘not listened to at all’ (Ockenden’s words) or dismissed when they raised concerns or sought answers know this already.
It was evident, with hindsight, at least, from the smears the Mail was subjected to when we began exposing the rising mortality rate at SATH more than two years ago.
One the victims featured in that front page report was Pippa Griffiths, who died from a preventable infection in April 2016 which was not picked up by midwives.
A coroner would later rule that her death was avoidable and blamed a string of unforgiveable errors.
The inquest into her death heard how staff missed a crucial opportunity to save Pippa when her mother rang the maternity unit with concerns about her baby’s feeding.
A second was missed when she rang hours later to report bloody mucus, a sign of a bacterial infection.
This could have been treated had Pippa been taken to hospital as a matter of urgency.
After she was born at 8.34am, a midwife was due to visit for a check in the afternoon.
She failed to turn up. Pippa developed a purple rash later that night and stopped breathing.
Only at the inquest, a year after Pippa died, did her parents found out the truth.
‘We’ve fought for her and fought for the truth and ultimately she could have been saved,’ Miss Griffiths told us at the time.
Another tragedy highlighted in our coverage was Jack Burn who died from the same infection as Pippa Griffiths – group B streptococcus – in March 2015, only 11 hours after he was born.
His mother had been told nothing was wrong with her pregnancy but later found Jack had been distressed for 20 minutes before delivery.
Wright now works as a ‘continuous improvement consultant’ for an American consultancy that advises the NHS on patient safety.
The company he works for had a five-year contract with NHS England to help improve safety at five health trusts – including Shrewsbury and Telford; no, you have not misread that last sentence.
However selfless and courageous nurses and doctors have been – and continue to be – during the pandemic, however much we want to place the NHS on a pedestal, what happened in Shrewsbury and Telford is a stark reminder of the systemic failings inherent in some hospitals.
Nearly four in ten maternity services are failing to meet safety standards, according to the Care Quality Commission.
The health watchdog told MPS earlier this year that 39 per cent of units were rated as ‘requiring improvement for safety,’ with a further 1 per cent inadequate.
Equally alarming were the findings of Sir Bill Kirkup, who is leading a major inquiry into a maternity scandal at East Kent Hospitals and warned of a cover-up culture in the trust where up to 15 babies have died since 2011.
‘There are some units which actively conceal what they’re doing,’ he said.
‘When they get in sufficient trouble their response is to stop communicating with the outside world and disguise the failings that they’ve got.
My view is that a lot of it lies in the leadership of those units and the fact they become isolated and nobody can quite spot what is happening.’
This became an all-too-familiar pattern at Shrewsbury and Telford.
Take the tragic story of Thomas Gough at the Royal Shrewsbury in 2001. Doctors tried to resuscitate him but, after half an hour, were forced to declare him dead.
His parents were told this was because their son’s umbilical cord had become twisted around his neck.
Later, however, they discovered the truth from his medical records which showed there were warning signs throughout his mother’s labour that were never picked up.
The tragedy, in other words was avoidable, a word that crops up again and again in the Ockenden report.
The family sued the trust and were awarded £50,000, although the legal action was never about money. ‘Thomas should never have died and our lives would never have been shattered,’ his mum Vicky said at the time.
If lessons had been learnt then, how many other lives might have been saved?
At least 51 cases investigated by the Ockenden inquiry involved babies left severely brain-damaged after being starved of oxygen at birth, among them Cameron Dickens-Smith and Abbie Louise Everitt, born two weeks apart in 2004 at the Royal Shrewsbury.
‘We can’t comment on individual cases,’ a trust official told the local paper but readers were assured there were ‘robust systems in place for the training of staff and we regularly have external validations of these systems’.
The subsequent inquiry by the Healthcare Commission (now the Care Quality Commission) found there ‘were areas of concern’ including ‘inappropriate staff training’ but accepted that protocols were being introduced to prevent such tragic accidents happening again.
But they weren’t. The watchdog was guilty of ‘misplaced optimism’, the Ockenden report said.
‘Misplaced optimism’ or cover-up?
Finally, in 2017, due in no small part to the parents themselves, the then health secretary Mr Hunt ordered an independent investigation into the deaths.
Shrewsbury maintained that the rate of baby deaths at the trust, which handled 4,700 deliveries a year, was no worse than elsewhere in the NHS.
This was the line which had been peddled to bereaved families for so long. It was also a lie.
Between 2013 and 2016 it was 10 per cent higher than in comparable hospital trusts.
Babies continued to die because of repeated failures and mothers were often blamed for their deaths, the Ockenden report found.
Yet, the culture of ‘cover-up’ persisted. The trust commissioned the Royal College of Obstetricians and Gynaecologists (RCOG) to undertake a review, completed in 2017, which did conclude that mortality rates were above average.
But SATH delayed the publication of the report, only releasing it after paying the Royal College to produce another report that said all its recommendations had been implemented.
‘The RCOG regrets that the trust did not accept its initial report and waited six months to publish it alongside the addendum [addition],’ a spokesman for the Royal College said.
An NHS report into that particular controversy was more scathing. It found that the decision by former chief executive Mr Wright not to accept the original RCOG review was ‘driven primarily by concerns about the impact of publishing the report it its current form’.
It added: ‘In particular, the trust was worried about the potential public and media reaction … our view is that the primary purpose of the follow-up exercise from the trust’s perspective was to mitigate the perceived adverse impact of publishing the initial report.’
But then this was the same chief executive – and same trust – which accused us of scaremongering back in 2018.
Scandal to shame NHS
By Mario Ledwith, Claire Duffin and Liz Hull
Hundreds of babies died needlessly because of disastrous failings at a hospital trust, in the NHS’s worst ever maternity scandal.
A damning report, published yesterday, found that distraught mothers were routinely blamed for their children’s deaths by callous maternity staff.
Families said that a ‘toxic culture of bullying’ within the Shrewsbury and Telford Hospital Trust had allowed the shocking failings.
Over decades of woeful care, deaths of babies and mothers were often ignored by the trust or met with lacklustre investigations.
Former health secretary Jeremy Hunt said: ‘This is a tragic day for families across Shropshire, who have had it confirmed in black and white that hundreds of precious babies died needlessly.
Blame: Rhiannon Davies and baby Kate
‘Babies’ skulls were fractured and bones were broken in excruciatingly traumatic births that would never have happened if mothers’ wishes had been listened to.’
The Daily Mail was accused of scaremongering by the hospital trust after our revelations detailing how suspicious maternity deaths at its hospitals were spiralling in 2018. The shocking report details how:
- The maternity unit preferred natural childbirth – and was slow to move to caesarean sections when necessary.
- Oxytocin, a drug commonly given in childbirth, was used incorrectly to increase contractions with often disastrous results.
- Staff regularly resorted to forceps deliveries against recognised protocols, inflicting terrible injuries.
- Midwives routinely took the lead during births and were reluctant to alert more senior consultants when problems arose.
- Blatant shortcomings that, if detected, could have prevented scores of other deaths from unfolding were therefore not spotted, with staff instead ‘focused on blaming the mothers’ in some cases.
- As well as babies dying, others suffered brain damage as a result of the way they were born.
The review, carried out by senior independent midwife Donna Ockenden into an initial 250 of 1,862 cases, found that grieving families seeking answers were ‘dismissed or not listened to at all’.
Staff including consultants used ‘flippant’, ‘abrupt’ and ‘dismissive’ language to mothers who were clearly in distress, which ‘compounded’ their grief.
In one case, a distraught mother was described as ‘lazy’ by an obstetrician during an incident in 2011 and told that her suffering was ‘nothing’.
Geoff Wessell, assistant chief constable at West Mercia Police, said the force’s investigation into possible corporate manslaughter is continuing.
While no staff were named in yesterday’s interim report, it emerged that NHS bosses and senior health staff will be ‘named and shamed’ in the final report next year.
The report said that its study of 1,862 suspect cases will eventually be the largest ‘mass review relating to a single service in the history of the NHS’ when completed.
Miss Ockenden said families had been left ‘utterly bereft’ because of healthcare failings. ‘Their suffering has been made worse as a result of the handling of the incidents by the trust,’ she said.
Richard Stanton, who was praised for unearthing the scandal with his wife Rhiannon Davies after the death of their newborn daughter Kate Stanton-Davies in 2009, said the report was ‘bittersweet’.
He added: ‘This was all preventable. What is clear is that there has been an absolute toxic culture from the top down at the trust – it’s a bullying culture that has enabled this.’
Miss Davies said: ‘This is the 21st century. This is not Victorian England. How did this happen? How, why did no one speak out at the hospital trust?
‘There are obstetricians calling mothers lazy, women lying there screaming in agony for hours because they need an intervention and people doing nothing.’
Kim Thomas, chief executive of the Birth Trauma Association charity, said: ‘Mothers and babies have died as a result of poor team-working, a failure to learn from mistakes, a culture of cover-up and an obsession with keeping caesarean rates low.’
Miss Ockenden called for a series of recommendations in the report to be implemented ‘as a matter of urgency’ in maternity wards.
NHS trusts across England were told to implement seven recommendations while the Shropshire trust was given 27 actions to carry out.
Ministers promised to make urgent changes to prevent a repeat of the scandal.
The report found that an unwillingness to carry out caesarean sections underpinned health failures at the trust’s two hospitals – the Royal Shrewsbury and the Princess Royal in Telford, which serve around half a million people.
Women were given ‘little or no freedom to express a preference’ for C-sections within the trust, where rates for the procedure were 8-12 per cent below the average at other trusts in England.
The Ockenden review was initially expected to look at only 23 cases after being ordered by Mr Hunt, then health secretary, in 2017.
But after a flurry of new cases emerged following publicity of the failures, yesterday’s review looked at an initial tranche of 250 cases and involved interviews with 800 other families.
Most of the cases covered by the report occurred between 2000 and 2019 but several are thought to date back as far as 1979.
The trust was already one of the worst performing in the country after being placed in special measures in 2018, and earlier this year inspectors said standards had fallen further.
Louise Barnett, chief executive of the trust, yesterday apologised for the ‘pain and distress that has been caused to mothers and their families due to poor maternity care at our trust’.
Parents’ 11-year fight for justice
The parents who unearthed the Shropshire maternity scandal said that the arrogance of NHS bosses at the trust let failings continue for decades.
Richard Stanton and his wife Rhiannon Davies were yesterday praised by review author Donna Ockenden for their ‘unrelenting commitment’ to
uncovering the truth. The couple’s daughter Kate Stanton-Davies died just hours after her birth at a midwifery-led unit in Ludlow in 2009. Mr Stanton, 50, said: ‘To get here and see the number of cases and the harrowing stories is just really sad. This should never have happened.’
Richard Stanton and his wife Rhiannon Davies
Miss Davies, 46, was sent to the unit after tests in the weeks before her daughter’s birth failed to classify her as a high-risk patient.
Kate became gravely ill after her worsening condition went unchecked by midwife Heather Lort, who had failed to put her in an incubator.
It took a further half an hour before the paramedics were called and Kate was airlifted to Birmingham’s Heartlands Hospital over 40 miles away, where she died shortly after arriving.
Mr Stanton and Miss Davies had to wait three years for a jury inquest to find out why she died.
The 2012 hearing confirmed that Kate’s death was avoidable and was attributable to serious failings in her care. Mr Stanton said midwives were ‘allowed to go about doing what they wanted unchallenged’.
He added: ‘There’s a huge arrogance at this trust among some of the senior
staff and consultants, which is pertinent to maternity care’. Miss Davies
added: ‘I wanted to lie down and die to be quite frank with you.’
This pain has to end
Trust bosses need to do more to stop other families ‘going through the pain we have’, says a mother whose baby died a day after she was born.
Kayleigh Griffiths’s daughter Pippa, died on April 27, 2016 after midwives failed to recognise a deadly infection.
She was delivered at home in Shropshire and Mrs Griffiths, her husband Colin and Pippa’s big sister Brooke were delighted.
Pippa, died on April 27, 2016 after midwives failed to recognise a deadly infection
But later the couple became concerned about Pippa’s feeding and were
told a midwife would return but no one came, an inquest heard.
The next day their daughter had vomited brown mucus, developed a purple rash and later stopped breathing.
Emergency services helped Pippa breathe again but she later died.
Tears: Kayleigh and Colin Griffiths
The trust accepted she could have been saved if the infection had been spotted earlier.
Mrs Griffiths said: ‘They need to own the failure instead of saying we are sorry.
‘Your children say to you: ‘Why are young doing this again mum?’… It is because we don’t want any other families to go through the pain that we have.’
Now take them to court
A young mother whose baby died a Shrewsbury Hospital said she hoped criminal prosecutions would follow.
Katie Wilkins was just 17 when busy midwives left her in labour with her first child for more than 48 hours.
Despite being 15 days overdue, Miss Wilkins, 25, was ‘forgotten’ in a side room.
Anger: Katie Wilkins and partner Dave Jackson
When a midwife came to check on her they realised her baby’s heartbeat could not be found and her daughter Maddie was delivered stillborn on February 21, 2013.
A post-mortem revealed that there was nothing wrong with the baby and the hospital admitted Maddie could’ve survived had Miss Wilkins’s induction been ‘more timely’.
Miss Wilkins, who has two children with partner Dave Jackson, 46, said: ‘I hope now that the police will take it further and there will be criminal prosecutions.’