What went so wrong in Shrewsbury and Telford maternity services that hundreds of babies were allowed to die unnecessarily? Trust bosses hid mistakes and chose not to investigate, workers were scared and stretched beyond their limits, and concerned parents were ignored or lied to. Last week’s Ockenden Report painted a horrific picture of despair amid chaos in hospitals and units desperately short of staff.
As one worker told the inquiry, “This wasn’t just a maternity unit in chaos and under pressure, this was a whole organisation where it was difficult to find an area which was not under pressure.” Senior midwife Donna Ockenden and her team pulled no punches when they described a hospital trust as disastrous after nearly 20 years of cuts, neglect and demoralisation.
Another worker described the mayhem that reigned when a woman was preparing to give birth in a unit that was already overfull. She recalled that midwives in the labour ward would tell those in the antenatal ward, “No staff, no staff, I can’t take her, I can’t take her”.
The report notes that as the litany of mistakes in Shropshire became clear, senior leadership even tried to deflect criticism by blaming mothers for their babies’ deaths. The catalogue of avoidable mistakes would have remained hidden if it were not for the tireless fight of bereaved families.
Rhiannon Davies, who lost her daughter in 2009, and Kayleigh Griffiths, whose daughter died in 2016, took on the entire medical establishment. They wanted the truth about why their children died. In the process they found a host of other families that also lost babies unnecessarily or whose children suffered terrible sickness.
Despite facing a deliberate strategy of obstruction and lies, Davies demanded answers from first the midwifery unit where she had given birth. Then from the NHS Trust that ran it, then the coroners, the Health and Safety Executive and the Care Quality Commission.
“Midwives from the midwife-led unit refused to speak to me, the hospital trust sent insensitive communication and inaccurate information,” she told Radio Four’s Today programme. “Because of the treatment we were given, it led to us asking more questions and seeking greater clarity. It became a complete and utter fight to try to get to the truth about what happened to my baby and why she died.”
They worked to amass enough evidence to make the case that maternity services in Shropshire were routinely dangerous. Davies and Griffiths then presented their files to the department of health, and its then boss, health secretary Jeremy Hunt. “Kayleigh and I went through obituaries, we went through coroners’ records,” recalls Davies. “We knew that because there were so many similarities between our two cases that we were not the only ones.”
The pattern of failure they collated was so compelling that the government set up the Ockenden inquiry. Its final report says that Davies and Griffiths were right. There was repeated poor care in maternity services in the period between 2000 and 2019. In exhaustive detail Ockenden describes cases where mothers should have been assessed as being at high risk of having a difficult birth. At this point they should’ve been sent to units led by consultants, but instead remained at midwife-led units until it was too late.
The report also catalogues many births where chances to spot warning signals and call for more intervention were missed because basic checks were not done properly or regularly. This has been the signal for much of the press to accuse midwives of being largely to blame for the scandal. Some journalists have even accused them of being fixated on natural births for “ideological reasons”.
But Ockenden’s final report does not reach that conclusion and instead puts emphasis on poor staffing, poor training and poor leadership. These can only be understood in the context of years of savage cuts. The Trust’s failure to properly investigate cases where babies died or were injured because of errors meant that opportunities to learn from were missed.
And many external reports gave the impression that the maternity services in Shrewsbury were either good, satisfactory or improving. The report uncovers dangerous conditions where there were too few staff with nowhere near enough experience to cope with what they were faced with. When women, babies and midwives needed help there were often no doctors and consultants available.
“The number of consultants, and the number of women that they were responsible for meant that timely reviews of women on the labour ward, or in other inpatient areas would have been very difficult, if not impossible, to provide at times,” the report says. “Therefore, midwives wishing to escalate clinical concerns would have been regularly working in an environment in which it would have been difficult to obtain a timely senior obstetric review.”
The culture in maternity services was often hostile. Bullying made it hard for people to speak out about dangerous practice, or ask colleagues for support. Even some who spoke to the inquiry asked for their anonymised testimony to be left out of the final report for fear of reprisals. And it wasn’t just a shortage of doctors that made things difficult.
Labour ward coordinators are experienced midwives that play a vital role in ensuring the safety of women and their babies. The coordinators are supposed to be “supernumerary”—that is they should not have cases of their own, so they can best support and lead their team of midwives. But the report found that in Shropshire this was rarely the case.
Staffing was routinely so low that coordinators had a caseload of their own. And outside of normal hours they also had responsibility for “overseeing the clinical activity across the whole of the Trust’s maternity services.”
One midwife recalled to the inquiry what that meant. “I was, I think, three months into my labour ward rotation and I kept pressing the call bell saying she’s bleeding a lot quicker than I’d like, you know, I think we’re up to 500mls now, and the coordinator kept coming in saying I’m on a ward round, it’ll have to wait. I felt like I’d let that woman down because my skills weren’t good enough. That’s how I was made to feel when, actually, that was a situation I should have had help in. If she was bleeding that much I should have had help.”
It’s clear from the report that the Trust’s failings are being borne mostly by midwives. The price of that is fear and demoralisation—and the potential for a kind detachment that occurs when people are repeatedly pushed beyond normal limits. The question of what happens now looms large in maternity services all over Britain. Already shockingly poor care has been exposed in east Kent, Essex, Morecambe Bay and Nottingham.
The Ockenden report concludes by rightly insisting upon immediate action. Its key focus is on funding, staff training and most importantly dealing with the lack of midwives and doctors. There are over 2,000 midwifery vacancies in the NHS and filling them is key to ensuring safety. The Royal College of Midwives reports that many existing staff plan to leave within the next few years.
Despite government promises to accept the report’s recommendations in full, the Tories’ record of staffing and funding the NHS is appalling. They cannot be trusted to implement the promises they make. If we are to stop the tragedy of needless maternity deaths and injuries, Ockenden needs to be a turning point. It should be a launch pad for a serious movement in defence of the NHS, its staff, and for the resources they so badly need.
Former bosses behind the scandal went on to make money elsewhere in healthcare, with four profiting from the NHS. Neil Taylor was head of Shrewsbury hospital when the first baby deaths analysed by the Ockenden Report occurred. In 2003 he became the head of the new NHS Trust before being sacked for fraud. Tom Taylor took over and was in charge until 2010. He is still working as the chair of the NHS counter-fraud authority.
Adam Cairns was chief executive until 2012 when he moved to Qatar to take up a position with the Hamad Medical Corporation. Its maternity facility is home to the county’s largest neonatal intensive care unit. Peter Herring ran the Trust when it was found to have “completely failed to learn lessons”. He stayed in post until 2015 even after the organisation was put in special measures. He has since been an interim chief executive at another NHS Trust.
Herring was followed by Simon Wright until 2019 when he resigned after regulators criticised his leadership. He has since set up a firm that specialises in coaching executive healthcare leaders and has a contract with the NHS.
Shrewsbury and Telford NHS Trust was known to have a number of problems from its inception in 2003. But the perception was that until 2017 the maternity service was not a major risk. A number of investigations prior to then could have proved otherwise.
In 2013 a review by clinical commissioning groups brushed off higher than average death rates among babies born in the Trust. It said, “There was an openness and transparency in reporting and investigation culture, which has led to a higher reporting of serious incidents than would have been reported elsewhere”.
In March 2014, the NHS Litigation Authority assessed the maternity service for clinical care and high-risk conditions. The Trust was awarded the “Level 3” standard—the highest grade available. The Care Quality Commission conducted a report in 2015. Their overall rating for maternity services was “good”.
An internal inquiry in 2017, the Ovington Review, was set up following concerns raised by bereaved parents and the increased perinatal mortality rate between 2007 and 2017. It found there should be more transparency, more investigations and learning from incidents. And it recommended that staff from outside the Trust be brought in to conduct inquiries. But it’s unknown whether the recommendations were acted upon as the Ockenden Report team was not provided with evidence of any outcomes.
That same year the Royal College of Obstetricians and Gynaecologists prepared a damning report into Shropshire’s maternity services. It highlighted many of the same issues now addressed by Ockenden. But the Trust bosses refused to accept the findings until an additional addendum was added to the beginning of the report.
This noted there had been areas of improvement in the intervening period. Finally in 2018, a new report from the Care Quality Commission began to uncover the truth of just how badly things had gone wrong. But by now it was too late—especially for the families who had lost their babies.
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