Hospital trust offers 'wholehearted apologies' after damning report into maternity care

The Ockenden report found that at least 201 babies and nine mothers could have been saved if Shrewsbury and Telford Hospitals Trust had provided better care.

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

It found that leaders and midwives were determined to keep Caesarean section rates low, despite the fact this repeatedly had severe consequences.

The inquiry is the largest ever into a single service in the history of the health service and has wide-ranging implications for the maternity in the NHS.

Louise Barnett, chief executive at the Shrewsbury and Telford Hospital Trust said: "Today's report is deeply distressing, and we offer our wholehearted apologies for the pain and distress caused by our failings as a trust.

"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.

"Thanks to the hard work and commitment of my colleagues, we have delivered all of the actions we were asked to lead on following the first Ockenden report, and we owe it to those families we failed and those we care for today and in the future to continue to make improvements, so we are delivering the best possible care for the communities that we serve."

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.

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

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.

A review of 498 stillbirths found that 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% of the stillbirths were never investigated by the trust.

There were also significant or major concerns over 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 (within the first seven days of life) had "significant or major concerns" over care which might have resulted in a different outcome.

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".

The report noted that internal reviews of the deaths were poor, with some women blamed for their own deaths.

It 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.

Investigators pointed to "repeated failures" to escalate concerns, delays in women being admitted to the labour ward, delays to women being assessed for emergency intervention or to be seen by consultants.

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.