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Shrewsbury and Telford Hospital NHS Trust 'blamed' mothers for babies' deaths, initial inquiry confirms

A large number of women died in labour at Shrewsbury and Telford Hospital NHS (SaTH) Trust and some mothers were even blamed for their babies' deaths, the largest ever inquiry into maternity care has established.

The inquiry into Shrewsbury and Telford Hospital NHS (SaTH) trust, which has been criticized for some time, found deaths were often not investigated and an induction drug was repeatedly misused.

The review started 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 in 2016 from a Group B Streptococcus infection.

The interim report lists many traumatic birth experiences, including the deaths of babies due to excessive force of forceps, and stillbirths that could have been avoided.

Others detail 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.

The inquiry 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: "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."

In June, police launched an investigation into if there was evidence to support a criminal case against the trust or any individuals involved. This is continuing.

The inquiry, being led by senior midwife, Donna Ockenden, is examining 1,862 cases and initially studied 250 of these in a selection of cases between 2000 and 2018. It found there were 13 maternal deaths, which is disproportionately high.

While the report said the women were often correctly identified as being "high risk" due to existing medical conditions, little real action appeared to have been taken with junior doctors conducting assessments and no team working to ensure best care.

After each death "in some cases, no investigation was initiated" while in others "no learning appears to have been identified."

The report said "inappropriate language had been used at times causing distress," and there were cases "where women were blamed for their loss which further compounded their grief."

Ms Davies' daughter Kate was born "pale and floppy" at Ludlow Community Hospital and died after delays in transferring her to a doctor-led maternity unit.

She has fought for a review for 11 years and said: " I've never doubted my surety of what happened with Kate. The interim findings will hopefully bring this essential, critically required, change this trust has not been able to see it needs and that will hopefully ensure patient safety improves."

Her husband Richard added "The interim findings must impose emergency recommendations which are clearly needed to improve maternity care. No family should have to go through what me and Rhiannon and all the others have gone through."

The reports lists 27 actions the trust must immediately carry out.

Ms Ockenden said: "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. The work that follows owes its origins to Kate Stanton-Davies and her parents."

Former health secretary, Jeremy Hunt, who ordered an inquiry in 2017, tweeted: "This is a tragic day for families across Shropshire who've had it confirmed that hundreds of babies died needlessly. There’s nothing more cruel in life than losing a child but, to do so because of mistakes that were covered up, makes things infinitely more painful.Shrewsbury and Telford Hospital NHS (SaTH) Trust chief executive, Louise Barnett,  said: "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."

The seven actions outlined for maternity services across England include: Enhanced safety, listening to women and families, staff training and working together, managing complex pregnancy, risk assessment throughout pregnancy and monitoring fetal wellbeing.

As part of those seven actions, it also said there must be twice daily consultant-led ward rounds, seven days a week, during the day and night.