insiderblmMothers were blamed for their babies’ deaths and a large number of women died in labour at scandal-hit maternity unit, a review has found.
The inquiry into Shrewsbury and Telford Hospital NHS (SaTH) trust found deaths were often not investigated and an induction drug was repeatedly misused.
Rhiannon Davies said she never doubted what happened with her daughter Kate.
Seven “immediate and essential” actions have been made for all maternity services across England.
The review began in 2018 following campaigns led by two families. Richard Stanton and Ms Davies’ daughter Kate died hours after her birth in March 2009, while Kayleigh and Colin Griffiths’ daughter Pippa died from a Group B Streptococcus infection.
In June police launched an investigation to examine if there was evidence to support a criminal case against the trust or any individuals involved.
The report lists numerous traumatic birth experiences including the deaths of babies due to excessive force of forceps and stillbirths that could have been avoided.
Others recount repeated failures by staff to recognise mothers and babies in deteriorating conditions, including one mother whose baby died because staff were “too busy” to monitor her during labour.
It found letters and records “which often focused on blaming the mothers” rather than considering whether the trust’s systems were at fault. This was exacerbated by the attitude of staff, the report said: The parents of baby Kate and Pippa talk about the pain of losing their child
It said: “One of the most disappointing and deeply worrying themes that has emerged is the reported lack of kindness and compassion from some members of the maternity team.
“The fact that this was found to be lacking… is unacceptable and deeply concerning.”
The inquiry – the largest ever of NHS maternity care – is being led by senior midwife Donna Ockenden and is looking into 1,862 cases and initially examined 250 cases.
This first report looked at a selection of cases between 2000 and 2018 and found there were 13 maternal deaths, a rate that is disproportionately high.
While the report said the women were often correctly identified as being “high risk” due to existing medical conditions, little concrete action appeared to follow with junior doctors conducting assessments and no team working to ensure best care.
After each death “in some cases, no investigation was initiated” whilst in others “no learning appears to have been identified.”
Ms Davies’ daughter Kate was born “pale and floppy” at Ludlow Community Hospital and died after delays in transferring her from Ludlow to a doctor-led maternity unit.
She has fought for a review for 11 years and said: “I may sound arrogant but I’ve never doubted my surety of what happened with Kate.
“I knew I was right. The interim findings will hopefully bring this essential change, critically required change, change this trust has not been able to see it needs to embed and that will hopefully ensure patient safety improves and that is the only reason we’ve continued.”
The reports lists 27 actions the trust must immediately carry out.
Ms Ockenden said the first review and the work that follows “owes its origins to Kate Stanton-Davies and her parents”.
She added Kate and Pippa’s parents have shown “an unrelenting commitment in ensuring their daughter’s short lives made a difference to the safety of maternity care”.
