Shropshire maternity death numbers 'worse' than imagined as scale of scandal is laid bare
The Tory MP who ordered the Ockenden inquiry into mother and baby deaths at Shrewsbury has said the numbers were "worse" than he could have imagined at the start of the process.
The report, by maternity expert Donna Ockenden, found at least 201 babies and nine mothers could have, or would have, survived if Shrewsbury and Telford Hospitals Trust had provided better care.
Jeremy Hunt, who commissioned the report when he was Health Secretary in 2017, told the BBC Radio 4 Today programme that initially there were 23 instances of concern.
He said: "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."
MR Hunt said he hopes the report is "a wake up call", adding: "I think the families have played a really extraordinary role, but we have to ask ourselves, 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 rights, to make sure that processes are changed so these tragedies don't happen again?
"And what we have, I'm afraid, is a blame culture, even in this inquiry, doctors, midwives nurses at Shrewsbury and Telford said they were silenced, they were told that there would be professional consequences if they co-operated with the inquiry and we have to get rid of that blame culture and make it easy for people to speak openly and transparently when something goes wrong."
Tory MP Jeremy Hunt said NHS staffing was "a very important issue" and the health service is short of thousands of midwives.
"I believe Donna Ockenden is going to say some very strong words about that," he told BBC Radio 4's Today programme.
"And I'm extremely disappointed that today the Government looks at to vote down an amendment to the Health Bill, which has come back from the House of Lords, which would make sure that we didn't have these kinds of staffing shortfalls."
Asked if he had considered doing an NHS-wide review into maternity services, Mr Hunt said: "I think it would be wrong to say the progress hasn't been made. The number of baby deaths over the last decade has gone down by more than a third, and so the NHS is getting safer and maternity units are getting better at learning from mistakes.
"But we have still got a long way to go. I think this is a very, very sobering wake-up call and my biggest concern is that even the process of doing this investigation, which Donna Ockenden has done with incredible thoroughness, even that was hampered because people in the trust concerned were scared to speak openly, and that's what we have to tackle."
Louise Barnett, chief executive at the Shrewsbury and Telford Hospital NHS 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."
Telford & Wrekin Council leader Shaun Davies said: "Leader of Telford & Wrekin Council, Councillor Shaun Davies (Labour) said: "My heart goes out to the courageous families who shared their harrowing experiences with Donna Ockenden about the failures in maternity care at Shrewsbury and Telford NHS Trust. Without their significant contributions the report would not have the necessary impact to affect change. Their bravery in coming forward is a tribute to the babies they have loved and lost and others who have endured life changing injuries.
"The publication of this report is a watershed moment not only for the NHS but crucially for our local families who wanted to understand what happened to them and to ensure the future safety of maternity services in the region and beyond.
"I’m a local dad, to a child who was born in the care of the Trust just over five years ago and I’ve heard first hand perspectives from parents who have shared their own, deeply personal and moving stories. I am very conscious of the enduring distress and pain felt by many families.
"I am in regular touch with senior leaders at SaTH, seeking assurances that they are implementing changes. I do recognise there has been considerable strides in maternity care since the interim report and there are many members of staff as SaTH who work extremely hard to make sure parents and babies now have a positive experience. It is clear however that the Trust requires significant backing and investment into maternity, A&E and other services. For far too long, the much needed funding and resources hasn't arrived. Telford and Wrekin Council wants the best possible healthcare for our residents; we will continue to offer and provide support and challenge to the Trust."
Montgomeryshire MP Craig Williams also described the findings as "deeply shocking".
“I am appalled at the sheer numbers of families who have been affected, as well as the scale of negligence and systematic failings which was shown by the Trust over so many years," he said.
“My deepest sympathies go to all those who have been traumatised and failed so badly. It is vital that the trust accepts responsibility for the review’s findings and acts now, which at the very least I hope will give some reassurance to all those who have suffered so terribly.”
Clea Harmer, chief executive at Sands, a stillbirth and neonatal death charity, said: “Today’s final report from the Ockenden review must be a watershed moment for maternity safety.
“Every mother has the right to expect safe maternity care for herself and her baby. It is essential that the Government supports Trusts to implement the immediate and essential actions laid out by Donna Ockenden.
“A tragedy of this scale must never be allowed to happen again. Time and again reports have told us what’s going wrong in failing maternity units. Action is now urgently needed at every level, from clinical training to management ethos.
“We must change the culture that has silenced bereaved parents and prevented lessons being learned, so that no babies die because of avoidable mistakes.
“Listening to parents can save lives, but hospitals need enough staff, resources and support to do this effectively. Trusts which are struggling must be identified earlier and offered support so that babies and mothers are kept safe and well.
“Sands is working hard to save babies’ lives. If the UK is to be the safest place in the world to have a baby, we need a culture of openness where human errors or systemic failings can be acknowledged, and lessons learned by Trusts.
“Today’s news about the events within the Shrewsbury and Telford Hospitals NHS Trust will have been very painful for those who have been affected directly and anyone affected by pregnancy loss or the death of a baby. We are here to support anyone who needs us.”
Sands is here to support anyone affected by the death of a baby. Sands’ free Helpline is available on 0808 164 3332 10am to 3pm Monday to Friday and 6-9pm Tuesday and Thursday evenings. You can also email helpline@sands.org.uk for support. www.sands.org.uk/support
