Intended for healthcare professionals


Maternity care failings in Shropshire stretch back four decades

BMJ 2019; 367 doi: (Published 22 November 2019) Cite this as: BMJ 2019;367:l6656
  1. Jacqui Wise
  1. London

A leaked internal report about maternity care at Shrewsbury and Telford highlighted failings that led to deaths and injuries over 40 years. Jacqui Wise reports

What is this leaked report?

Midwife Donna Ockenden is leading an independent review of maternity care, including cases of serious and potentially serious concern, at Shrewsbury and Telford Hospital NHS Trust, which runs the Royal Shrewsbury Hospital and Telford’s Princess Royal.1 The report, leaked to the Independent newspaper, appears to be a confidential status update submitted last February, produced at the request of NHS Improvement and not meant for publication.2

When was the review set up?

The Ockenden inquiry was set up in 2017 by the then health secretary for England, Jeremy Hunt, in response to a campaign led by two sets of parents: the Stanton-Davies, whose daughter Kate died shortly after birth in 2009, and the Griffiths, whose daughter Pippa died shortly after birth in 2016.

What is the scope of the Ockenden inquiry?

The inquiry was initially asked to examine 23 cases in which failings in maternity care were alleged. In August 2018 its scope was expanded to look at 40 cases between 1998 and 2017, then later to 100. The figure has now grown to more than 270, covering the period from 1979 to the present day. In June 2019 NHS improvement asked for all cases since 1998 of deaths, stillbirths, and babies born with brain damage to be looked at, but it said that not all cases were necessarily the result of substandard care.

What does the leaked report say?

The leaked report highlights 42 deaths of babies (22 stillbirths, three deaths during pregnancy, and 17 deaths after birth) and of three mothers at the trust between 1979 and 2017. There were also 47 other cases of substandard care and 51 cases of cerebral palsy or brain damage. It says that there were repeated clinical errors, compounded by substandard follow-up investigations that failed to ensure that lessons were learnt. Bereaved families were treated with “a distinct lack of kindness and respect,” with examples including deceased babies given the wrong names in writing or referred to as “it.” There was a long standing lack of transparency, honesty, and communication with families when things went wrong. Many grieving families were wrongly told that they were the only ones affected and that lessons would be learnt. The report identified specific failures, including staff failing to realise that labour was going wrong, inadequate monitoring of fetal heart rates during labour, poor risk assessment during pregnancy, and babies left brain damaged from group B streptococcal infection or meningitis that could have been treated with antibiotics.

When will the final report be published?

A fuller investigation into avoidable baby deaths at the trust is continuing, but it is not known when the final report will be published. Ockenden said that she had listened to the families involved, who made it very clear that they wanted one, single, comprehensive independent report covering all known causes of potentially serious concern in the trust’s maternity services.

When were concerns first raised?

The leaked report says that regulators were aware of problems at the trust as far back as 2007, when the Healthcare Commission, a forerunner of the Care Quality Commission, highlighted concerns about injuries to babies.

What has the Care Quality Commission done?

The CQC’s latest inspection report, published in November 2018, rated the trust as inadequate and placed it in special measures.34 It made several recommendations regarding maternity services, including a review of the processes concerning women at high risk and of its policy on reduced fetal movement.

Have there been previous reviews?

In July 2017 the trust commissioned the Royal College of Obstetricians and Gynaecologists to assess its maternity services as part of a non-regulatory and advisory review. The college submitted its report in December 2017, making 37 recommendations to ensure improvements.5 The college criticised the trust for not publishing this report until July 2018.

Could doctors be struck off?

The General Medical Council has said that it is in contact with the trust and has asked NHS England and NHS Improvement for details of any concerns about individual doctors. Anthony Omo, the GMC’s general counsel and director of fitness to practise, said, “Where we receive details of any such concerns we will take appropriate action to protect patients and public confidence in doctors. All doctors have a responsibility to take action if they are aware that patient safety may be put at risk.”

Could the trust face corporate manslaughter charges?

West Mercia Police has said it is liaising with the inquiry and awaiting its findings before it considers any criminal proceedings.

What is the trust’s response?

Paula Clark, the trust’s interim chief executive, said, “I would like to reassure all families using our maternity services that we have not been waiting for Donna Ockenden’s final report before working to improve our services. A lot has already been done to address the issues raised by previous cases. Our focus is to make our maternity service the safest it can be. We still have further to go but are seeing some positive outcomes from the work we have done to date.”

Is this the UK’s biggest maternity scandal?

It seems so. Until now the worst ever maternity scandal was at University Hospitals of Morecambe Bay NHS Foundation Trust. An investigation in 2015 found significant failures of care in the maternity unit at Furness General Hospital in Cumbria that may have contributed to the deaths of three mothers and 16 babies between 2004 and 2013. Different clinical care in these cases would have prevented the death of one mother and 11 babies, the report concluded.67


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