Maternity tragedy: investigation into Shrewsbury and Telford Hospital NHS Trust

The full and final report arising from the independent review into Shrewsbury and Telford Hospital NHS Trust has today been released. Today's final report, released by Donna Ockenden, Chair of the Review, makes for devastating reading, identifying that at least 210 deaths could have been avoided and that nearly 100 babies suffered injury as a result of a failure to appropriately monitor and take action during labour. This may lead to brain injury and cerebral palsy both of which can have a very serious impact upon their future.

The review has identified repeated failures by the Trust that took place between 2000 and 2019. The final report acknowledges there were hundreds of cases where the Trust failed to undertake serious incident investigations, this is in addition to the identified failings in respect of management of pregnancy and labour. This only goes to compound the devastating impact that the events at Shrewsbury and Telford Hospital NHS Trust have had on nearly 1500 families who have taken part in the review. At least 201 babies could have lived if their care had been better including 131 who were stillborn and 70 who died soon after birth. Nine mothers also died avoidable deaths. There were 94 cases where babies suffered avoidable long-term injuries including brain damage caused by a lack of oxygen during the labour and their birth. Stark findings with a heart breaking impact upon all those involved. Mothers were not being listened to and in some cases were being blamed themselves for the loss of their babies. The Trust was noted to favour natural birth with a reluctance to perform caesarean sections which resulted in a number of deaths. There was a failure to properly assess the risk of patients and a failure to correctly monitor babies during labour. If a fetal heart rate is not monitored correctly then this can lead to catastrophic consequences including brain injury, cerebral palsy and sadly death of the baby. Ms Ockenden has remained passionate throughout in gaining answers for the families involved and wanted Hospital Trusts across the country to take note and make improvements. She states “Going forward, there can be no excuses, Trust boards must be held accountable for the maternity care they provide. To do this, they must understand the complexities of maternity care and they must receive the funding they require...A death of a mother or baby, or a birth incident which results in an injury should never be ignored. Thorough and timely expert investigations have to be undertaken which result in meaningful actions that improve quality of care, diagnosis and processes going forward” This final report shows that at Shrewsbury and Telford Hospital NHS Trust the NHS maternity service failed. They repeatedly failed to investigate, failed to learn and failed to improve. Such failures have impacted so many lives. We can only hope that this extensive review leads to a major overhaul of the maternity services across England and that we do not see events like this happen again in the future. Freeths solicitors have considerable experience and expertise in representing and securing settlements for clients in cases where there has been substandard care leading to stillbirth, death during pregnancy, neonatal death, brain injury and cerebral palsy. Karen Reynolds, Head of the Derby Clinical Negligence team at Freeths has pursued and settled dozens of obstetric claims against University Hospitals of Derby and Burton Foundation Trust including claims involving cerebral palsy, brain injury and stillbirth. When considering the Ockenden Report, Karen Reynolds comments “I have investigated many obstetric and gynaecological claims against University Hospitals of Derby and Burton NHS Foundation Trust and can identify similarities with those issues identified within the Ockenden Report. I hope that all Trusts read through this report and implement the findings into their own maternity services in the hope that such failings will not be repeated in the future”. Karen was part of the landmark case of Webster v Burton Hospitals NHS Foundation Trust [EWCA Civ 62] which was heard by Court of Appeal and found in favour of parent choice. The case highlighted that patients have a right to be informed about the risks involved in their treatment and make decisions accordingly. Had the claimant's mother been able to make informed consent in respect of the delivery of her child then the subsequent significant brain injury and disabilities suffered would have been avoided. Karen is also accredited to be on the panel of solicitors for AvMA, Action against Medical Accidents, an independent patient safety charity, providing advice and support to patients. Please see our designated Claims Against Maternity Services page for more information.

If you are concerned about care which you or a loved one have received, please contact a member of our national team for a free, informal discussion.