Seven “immediate and essential” actions have been identified for maternity services across England, after the independent inquiry into Shrewsbury and Telford Hospital Trust found repeated failures that led to avoidable deaths of mothers and babies, in an interim report.
The review of the first 250 cases found that the trust repeatedly misused induction drugs and failed to recognise or act on deteriorating conditions. Numerous traumatic experiences of the mothers and babies in their care were listed, including excessive force of forceps and avoidable stillbirths.
Lack of kindness and compassion
Letters and records reviewed by the inquiry noted a pattern of “blaming the mothers” rather than investigating the actions of staff or trust practices, revealing a “toxic” environment perpetuated by indifference and lack of compassion within maternity teams and the trust’s senior management.
The results come after findings that 23% of NHS trusts failed to notify families of unforeseen incidents occurring during birth, and after investigations into maternity care at the East Kent NHS Foundation Trust, suggesting a widespread attitude of disregard for the needs of families by those charged with their care at such a vulnerable time.
A search for the truth
Beginning in 2017 with an investigation into seven baby deaths within two years, the Shrewsbury and Telford investigation exposed evidence of a far more deep-rooted issue. It was vastly expanded in scope and will consider around 1,862 cases occurring between 1998 and 2017. More than 800 families have been involved to date.
Senior midwife Donna Ockenden, who led the inquiry, commended the unrelenting commitment of the families behind the inquiry.
Rhiannon Davies and Richard Stanton have spent the last 11 years pushing for an independent inquiry, following the death of their baby daughter Kate just hours after her birth. Kayleigh and Colin Griffiths led a campaign for review after their daughter Pippa died of a Group B streptococcus Infection when she was one day old. They expressed hope that the report would bring about critical change to improve the standard of maternity care.
Ongoing investigation
Louise Barnett, chief executive of the trust, apologised in a statement for the “pain and distress that has been caused to mothers and their families.”
She assured patients and their families of the trust’s commitment to implementing all actions in the report, which include enhanced safety, listening to women and families, staff training and working together, managing complex pregnancy, risk assessment throughout pregnancy and monitoring fetal wellbeing.
Following publication of the interim report, West Mercia Police confirmed in a statement that their investigation into evidence of a criminal case against the trust remains ongoing.
Ally Taft, partner with Medical Accident Group, said; “The contents of the report make for harrowing reading. It is devastating that failures of such magnitude were allowed to continue for so long. The seven essential actions outlined should be a minimum standard of care for families going through the vulnerable and often daunting experience of pregnancy and birth.
“This interim report represents an important step towards achieving recognition of, and accountability towards, the families harmed by the trust’s many failures. We hope that it also represents a much-needed change in the attitudes and practices of maternity care across the country.”
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