Baby deaths probe finds ‘immediate and essential’ action is needed to improve maternity care

A probe into the death of babies babies at Telford hospital has found ‘immediate and essential,’ action is needed to improve maternity care across the whole of England – as a health minister slammed an NHS trust’s ‘shocking failings’. 

The inquiry into deaths and allegations of poor care at the Shrewsbury and Telford Hospital NHS Trust (SaTH) was set up in 2017 and is now examining the cases of 1,862 families, with the majority of incidents occurring between 2000 and 2019.

The scandal came to light following campaigning from bereaved families, notably Richard Stanton and Rhiannon Davies who lost their baby Kate in March 2009. 

In June police opened an investigation into failings at two hospitals where dozens of babies died or suffered brain damage. 

Responding to the report, patient safety and maternity minister Nadine Dorries said she expects SaTH to act on the recommendations immediately following ‘shocking’ failings at the trust.

The ’emerging findings’ report was published on Thursday, based on a review of a selection of 250 cases of concern, which include the original 23 cases which initiated the inquiry.

A senior midwife has said 27 actions coming from the independent review are ‘must dos that need to be implemented now at pace’

Former senior midwife Donna Ockenden, chair of the independent maternity review, described the initial recommendations – including a call for risk assessments throughout pregnancy – as ‘must dos’ which should be implemented immediately.

Ms Dorries said in a statement: ‘My heartfelt sympathies are with every family who has been affected by the shocking failings in Shrewsbury and Telford Hospital NHS Trust’s maternity services.

‘I would like to thank Donna Ockenden and her team for their hard work in producing this first report and making these vital recommendations so lessons can be learnt as soon as possible.

Richard Stanton and Rhiannon Davies helped raise awareness of the scandal, following the death of their baby, Kate (pictured with Rhiannon), in 2009. Dozens of newborns died or suffered brain damage at two hospitals run by the trust

Richard Stanton and Rhiannon Davies helped raise awareness of the scandal, following the death of their baby, Kate (pictured with Rhiannon), in 2009. Dozens of newborns died or suffered brain damage at two hospitals run by the trust

‘I expect the trust to act upon the recommendations immediately, and for the wider maternity service right across the country to consider important actions they can take to improve safety for mothers, babies and families.

‘This Government is utterly committed to patient safety, eradicating avoidable harms and making the NHS the safest place in the world to give birth.

‘We will work closely with NHS England and Improvement, as well as Shrewsbury and Telford Hospital NHS Trust, to consider next steps.’

Commenting on her initial findings, Ms Ockenden said: ‘Over the last three years, this independent review team has been listening to and working with families and the trust in order to try and understand what happened.

‘We have been listening so that we can enable the trust and wider maternity services across England to be clear about the improvements needed.

‘This will ensure that maternity services are enabled to continuously improve the safety of the care they provide to women and families.

Maternity minister Nadine Dorries criticised Shrewsbury and Telford Hospital Trust for 'shocking failings,' that led to the deaths of newborn babies

Maternity minister Nadine Dorries criticised Shrewsbury and Telford Hospital Trust for ‘shocking failings,’ that led to the deaths of newborn babies

Babies whose lives should have been saved: Ella and Lola Jones

Twins Ella and Lola were starved of oxygen to the brain

Twins Ella and Lola were starved of oxygen to the brain

COULDN’T BE BOTHERED TO DO THEIR JOBS

In 2014, Kelly Jones, a mother of two, discovered she was pregnant with twin girls. 

During the pregnancy, she felt pain but despite repeatedly asking staff at the Royal Shrewsbury Hospital to assess her properly, she was ignored. 

By the time medics had eventually taken her seriously, her twin girls, Ella and Lola were stillborn. 

A letter from the Trust to Mrs Jones said that its investigation showed ‘that both babies had died from severe hypoxic ischemia (oxygen starvation to the brain) contributed to by delay in recognising deterioration in the foetal heart traces and missed opportunities for earlier delivery.’ 

The midwife came in crying, saying: ‘I’m so sorry, I’m so sorry,’ Mrs Jones said at the time. ‘My girls are gone because they couldn’t be bothered to do their jobs.’ 

Although the letter, dated June 2015, promised improvements in heart rate monitoring, two months later another baby died in similar circumstances. 

‘Today we are explaining in this first report local actions for learning and immediate and essential actions which we believe will improve maternity care, not only at this trust but across England so that the experiences women and families have described to us are not replicated elsewhere.

‘With a focus on safety, the 27 local actions for learning and seven immediate and essential actions in this report are ‘must dos’ that need to be implemented now at pace.’

The inquiry was commissioned following concerns raised by the parents of Kate Stanton-Davies and Pippa Griffiths, who died shortly after birth in 2009 and 2016 respectively.

West Mercia Police have also launched their own investigation to establish if there are any grounds for criminal proceedings.

The 27 local actions for learning involve recommendations around general maternity care, maternal deaths, obstetric anaesthesia and neonatal care.

Louise Barnett, Chief Executive at The Shrewsbury and Telford Hospital NHS Trust, said:

‘I would like to thank Donna Ockenden for this report but more importantly the families for coming forward.

‘As the Chief Executive now and on behalf of the whole Trust, I want to say how very sorry we are for the pain and distress that has been caused to mothers and their families due to poor maternity care at our Trust.

‘We commit to implementing all of the actions in this report and I can assure the women and families who use our service that if they raise any concerns about their care they will be listened to and action will be taken.’

‘If you are pregnant and have any questions about your current care, please contact your midwife.’

In 2014, Kelly Jones, a mother of two, discovered she was pregnant with twin girls. 

During the pregnancy, she felt pain but despite repeatedly asking staff at the Royal Shrewsbury Hospital to assess her properly, she was ignored. 

By the time medics had eventually taken her seriously, her twin girls, Ella and Lola were stillborn.  

Kate and Andrew Barnett from Newtown lost their son Jenson two days after his birth in June 2013, after he suffered brain trauma during an unsuccessful forceps delivery.  

Mrs Barnett, 35, told the Daily Mail in June how onsultants had to use forceps during the delivery, but they ‘could not work out which way his (Jenson’s) head was to apply them, so they applied them incorrectly.

‘When they went to pull him the bed shunted back and the forceps slipped off his head. I then got rushed for an emergency caesarean section.’ 

Jenson’s inquest was held the following year in March 2014, where a coroner ruled that the injuries he suffered during birth were ‘avoidable’.