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Shropshire maternity care failings: Victims hope inquiry will give answers

The final report of the review into Shrewsbury and Telford Hospital NHS Trust is due to be published.

29 March 2022

The families of babies who died or who were left seriously disabled due to catastrophic mistakes at an NHS trust are to receive the final report of an independent inquiry.

A major review into Shrewsbury and Telford Hospital NHS Trust, led by maternity expert Donna Ockenden, is due to be publish its findings on Wednesday, with implications for the whole of NHS maternity care.

Ms Ockenden’s team has examined 1,862 cases, mainly covering 2000 to 2019, making it the largest inquiry into a single service in the history of the NHS.

NHS maternity inquiry
The Royal Shrewsbury Hospital (Jacob King/PA)

The trust is currently ranked as inadequate by regulators.

The Rev Charlotte Cheshire, 44, from Newport, Shropshire, says her son Adam, now 11, looked unwell after his birth in 2011 but her concerns were dismissed by staff at the trust.

When it was finally discovered that he had Group B Strep infection, he was rushed to intensive care where he stayed for almost a month.

Ms Cheshire, who is suing the trust, says her son has been left with multiple, severe health problems and should have received treatment much earlier.

She told the PA news agency: “What I’m ultimately hoping is that all of the families get some answers.

“And then, in our individual cases, about how it’s possible for there to be such systemic failings over so many years, with seemingly either no-one noticing them, or potentially them being covered up.

“So I’m hoping first of all for answers, but secondly, I’m hoping, as a result of Ockenden, there are genuine learnings.

“Not the sort of, ‘oh, we’ll learn and get back to you’, but genuine learnings to improve maternity safety – primarily first of all at Shrewsbury and Telford, but secondly across the country as a whole.

“I don’t want any other family to have to go through what we’ve gone through.”

An interim report from the inquiry, published in December 2020 and covering 250 reviews, found a string of failings over two decades.

There was an unwillingness by Shrewsbury and Telford Hospital NHS Trust to learn lessons from its own inadequate investigations, leading to babies being born stillborn, dying shortly after birth or being left severely brain damaged.

Several mothers also died due to apparent failings of care.

Ms Ockenden’s team of investigators found some families were wrongly blamed when their babies died, were locked out of inquiries into what happened, and were treated without compassion and kindness.

She also noted the trust pursued a strategy of keeping Caesarean section rates low, despite the fact this led to poor care and severe consequences for some families.

In the interim report, Ms Ockenden noted that for around 20 years the Caesarean section rate at the trust was consistently 8% to 12% below the English average – something that was held up regionally and nationally as a good thing.

The review team were left with the clear impression “there was a culture” within the trust to keep Caesarean section rates low, because this was perceived as the essence of good maternity care, the study said.

The NHS is reported to have already paid millions of pounds in clinical negligence claims against the trust.

Ockenden report
Rev Charlotte Cheshire with her son Adam (Jacob King/PA)

Detective Chief Superintendent Damian Barratt, of West Mercia Police, told PA: “We launched an investigation in 2017 to explore whether there is evidence to support a criminal case against the trust or any individuals involved and this investigation remains ongoing.

“This is a highly complex and very sensitive investigation that has required us to speak to a large number of people to gather as much information as we can.

“We are also consulting with a number of medical specialists to ensure our investigation is thorough and that the best possible investigation is completed for the families involved.

“No arrests have been made and no charges have been brought, however we are engaging with the Crown Prosecution Service as our inquiries continue.

“Our thoughts remain with the families affected, and we can reassure the community that when there is an update on our investigation we will share this with the families involved first and foremost, and then to the wider public.”

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