Shrewsbury Maternity ScandalNovember 25, 2019
Mothers and babies have died or been injured for life in the biggest maternity care scandal the NHS has ever seen, stretching back 40 years. Shrewsbury and Telford NHS Trust have been under investigation since 2017 and a catalogue of failings have been identified within an interim report that has been leaked to the press.
The Trust runs both Royal Shrewsbury Hospital and Telford’s Princess Royal Hospital. Initially, the scope of the investigation was to examine 23 cases but this has grown to more than 270 cases including 22 stillbirths, 3 deaths during pregnancy, 17 deaths of babies after birth, 3 deaths of mothers, 47 cases of substandard care and 51 cases of cerebral palsy or brain damage. Devastatingly, the findings show ‘dozens’ of avoidable deaths.
Despite the investigation being launched in 2017, the report seems to reveal that regulators had been aware of problems since 2007, yet nothing was done to improve services.
The report has found that there was a ‘toxic’ culture and substandard care. It has also found that mothers were frequently treated unkindly by staff and their concerns were dismissed. Staff got dead babies’ names wrong in writing and in one case referred to a baby that had died as ‘it’.
Specific failures that have been identified include:
- A long-term lack of informed consent for mothers choosing to deliver their babies in midwifery-led units – where risks can be higher if problems occur which continues to the present day.
- A long-term lack of transparency, honesty and communication with families when things go wrong. This supported a culture that was disrespectful to families damaged by what they had been through.
- Failure to recognise serious incidents with many families still struggling to get the answers they deserve.
- Bereaved families routinely being told ‘they were not the only family’ and that ‘lessons would be learned’.
- A long-term failure to involve families in investigations that were often poor, extremely brief and overly defensive of staff.
- Not sharing learning, meaning repeated mistakes were often similar across cases. Failure to learn was present from the earliest case of a neonatal death in 1979 to cases at the end of 2017.
- A lack of support for families who have experienced significant loss and tragedy.
- A long-standing culture at the trust that is ‘toxic’ to improvement.
- Babies left brain-damaged because staff failed to realise or act upon signs that labour was going wrong.
- Inadequate monitoring of heart rates during labour and poor risk assessment during pregnancy, resulting in the deaths of some children.
- Babies left brain-damaged from group B strep or meningitis, which can be treated by antibiotics.
- A baby whose death from group B strep could have been prevented after the parents contacted the Trust on several occasions with concerns.
- A family being told they would have to leave if they did not ‘keep the noise down’ when they were upset after the death of their baby.
The interim chief executive of Shrewsbury and Telford Hospital NHS Trust has apologised unreservedly to families and assures patients that they are working to improve their maternity services.
This is sadly not the only Trust of which concerns about the quality of maternity care have been raised. In 2016, the National Maternity Review reported widespread problems with quality and safety, a failure to learn from mistakes, underreporting of safety incidents and missed opportunities to prevent stillbirths even when the mother had expressed concerns.
More must be done to learn from these reviews and investigations and implement safe maternal care in which mothers are supported and most importantly listened to. It is not acceptable that cases were not properly investigated and that lessons identified were not learned. It is not acceptable to allow a toxic culture in a maternity units to lead to so many lives changed forever by incidents that could have been prevented by safe maternal care.
This scandal should never have happened. None of these mothers and babies should have suffered in the way that they have and it is a disgrace that clearly expressed concerns were dismissed. It is unacceptable and urgent changes to hospital culture and maternity services must be made so that no more mothers and babies suffer in this way.
If you think you have been affected by substandard treatment at Shrewsbury and Telford Hospital NHS Trust you should seek the opinion of an expert lawyer as soon as possible. You may be able to bring a claim for medical negligence against the hospital that treated you and your baby during your pregnancy and labour. We understand the devastating impact these events have on mothers and their families and we are keen to get families the answers that they deserve.
Felicity Cottle is a solicitor in the Complex Injury team at Bolt Burdon Kemp specialising in Women’s Health. If you or a loved one has suffered an injury as a result of someone else’s negligence, contact Felicity in confidence on 020 7288 4836 or at firstname.lastname@example.org. Alternatively, complete our request for a call back form and one of the solicitors in the Complex Injury team will contact you to discuss further.