Shrewsbury and Telford Hospital: Babies and mums died ‘amid toxic culture’

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Richard Stanton

Babies and mothers died amid a “toxic” culture at a hospital trust stretching back 40 years, a report has shown.

The interim report, leaked to The Independent, of an investigation into maternity care at Shrewsbury and Telford Hospital NHS Trust also said children were left disabled.

Staff also got dead babies’ names wrong and, in one case, referred to a child as “it”.

The trust apologised and said “a lot” had been done to address concerns.

In 2017, then Health Secretary Jeremy Hunt announced an investigation into avoidable baby deaths at the trust, which runs Royal Shrewsbury Hospital and Telford’s Princess Royal.

It is being led by maternity expert Donna Ockenden, who authored the report for NHS Improvement.

Its initial scope was to examine 23 cases but this has now grown to more than 270, covering the period from 1979 to the present day.

The cases include 22 stillbirths, three deaths during pregnancy, 17 deaths of babies after birth, three deaths of mothers, 47 cases of substandard care and 51 cases of cerebral palsy or brain damage.

The report details the pain suffered by the families:

• Babies left brain-damaged because staff failed to realise or act upon signs that labour was going wrong
• A failure to adequately monitor heartbeats during labour or assess risks during pregnancy, resulting in the deaths of some children
• Babies left brain-damaged from group B strep or meningitis that can often be treated by antibiotics, and one whose death could have been prevented after its parents contacted the trust on several occasions worried about their newborn
• Many families “struggling” to get answers from the trust around “very serious clinical incidents” for many years and continuing to the present day
• One father whose only feedback following his daughter’s death was when he bumped into a hospital employee in a supermarket
• Members of one family being told they would have to leave if they did not “keep the noise down” when they were upset following the death of their baby
• One baby girl’s shawl was lost by staff after her death even though her mother had wanted to bury her in it
• A “long-term failure” to involve families in serious incident investigations, some of which were “overly defensive of staff”
• Families who told how “the trust made mistakes with their baby’s name and on occasions referred to a deceased baby as ‘it'”
• Multiple families “where deceased babies are given the wrong names by the trust – frequently in writing”

It also points to an inadequate review carried out by the Royal College of Obstetricians and Gynaecologists (RCOG) in 2017 and the “misplaced” optimism of the regulator in charge in 2007.

Rhiannon Davies and Richard Stanton, whose baby Kate died in 2009, were among the families who first pushed for the independent inquiry.

Mrs Davies said she was already aware of many of the issues raised by the report but said she was “shocked” by the length of time covered by the report.

“The devastating reality of Kate’s avoidable death, that I have to live with, is that she was condemned to her painful death by the culture at SaTh that wilfully refused to learn from earlier cases dating back decades,” she said.

“That is why I have fought every body and every institution in Kate’s name because no other baby will suffer the same harm while I have breath in my body.”

Shrewsbury and Telford Hospital NHS Trust (SaTH) said it had “not been made aware of any interim report” and awaited the findings of the full report.

Paula Clark, interim chief executive, said: “On behalf of the trust, I apologise unreservedly to the families who have been affected.

“I would like to reassure all families using our maternity services that we have not been waiting for Donna Ockenden’s final report before working to improve our services.

“A lot has already been done to address the issues raised by previous cases.”

However, the report warned lessons were not being learned and staff at the trust were uncommunicative with families.

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Ms Ockenden said the leaked document appeared to be an internal status update as of February 2019.

“This was produced at the request of NHS Improvement and was not meant for publication,” she said.

She said the independent review team was working to meet the family’s request for “one, single, comprehensive” report covering all cases of serious concern within maternity services at the trust.

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