Shrewsbury and Telford Hospital NHS Trust Maternity Scandal – Criminal Inquiry Begins

It has been announced this that a criminal inquiry has been launched into the Shrewsbury and Telford Hospital NHS Maternity Trust.  The Trust, responsible for both the Royal Shrewsbury and Telford’s Princess Royal Hospitals, is at the centre of the worst maternity scandal in the history of the NHS.

The Enquiry

The inquiry is being led by West Mercia Police, who will assess whether there is evidence of criminal actions by the Trust or specific individuals.  The cases involved range from as far back as the 1970’s and as recently as 2019.

The inquiry follows on from an investigation that was launched in 2017, initially to investigate 23 cases but soon grew to a list of hundreds, including stillbirths, deaths during pregnancy, deaths of babies after birth, deaths of mothers after birth, substandard care and cerebral palsy or brain damage.  The investigation found that ‘dozens’ of avoidable deaths had occurred, which is horrifying.

The investigation identified that there was a toxic culture at the Trust and substandard care was provided.  It found that mothers were frequently treated unkindly by staff and their concerns were dismissed.  Staff made mistakes identifying babies who had died, got their names wrong in writing and in once case referred to a baby that had died as ‘it’.  I cannot begin to imagine the additional pain and heart ache these actions caused to grieving parents.

The Investigation’s Findings

Specific failures that were identified included:

• A long-term lack of informed consent for mothers choosing to deliver their babies in midwifery-led units.  Risks can be higher on these wards if problems occur and this failing was identified as continuing 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.  Quite shockingly, the systemic failure to learn lessons 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

What does this mean for the Families?

I welcome the news that the scandal is being taken seriously enough to a warrant criminal investigation and I hope that this not only brings clarity and answers for families but also allows for learning throughout the whole NHS so that a scandal of this nature never happens again.  It will also mean that those responsible are held to account for their actions.

However, this does not erase the pain and suffering of every parent, child and family who have been involved.  The numbers are thought to reach 1,200 alleged cases and involve the deaths or lifelong injury of babies and mothers.

Should more be done?

Sadly, it is clear that there are deep issues in NHS maternity care, as can be seen from the emergence of the East Kent Hospitals University NHS Foundation Trust maternity scandal and the previous Morecambe Bay scandal.  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.  I have discussed this scandal in a separate blog which you can read here.

Failures in maternity care can lead to outcomes that have a devastating, life-changing impact for the families involved.  These families deserve answers and urgent changes to hospital culture and maternity services must be made so that no more families suffer.

This devastating scandal should never have happened.  These mothers and babies should not have suffered in the way they did and it is a disgrace that once these tragic events occurred the families were not granted the dignity of having their concerns listened to and investigated properly.  More must be done across the NHS to learn from these tragic events and other reviews and investigations into maternal care to ensure mothers are supported and listened to.  It is not acceptable that such a toxic culture was rife and led to so many lives being forever changed by incidents that could have been prevented by safe maternal care.