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Donna Ockenden, chair of the Independent Review into Maternity Services at the Shrewsbury and Telford Hospital NHS Trust, with families affected by incidents Jacob King via PA Images

Over 200 babies ‘could have survived’ if an NHS trust provided better care, report finds

The Ockenden inquiry is the largest into a single NHS service.

MORE THAN 200 babies could have survived had they been given better care at birth, a damning report into Britain’s biggest maternity scandal has said, prompting a government apology.

The inquiry – the largest into a single service in the 75-year history of the country’s state-funded National Health Service (NHS) – listed repeated failings at the Shrewsbury and Telford Hospital NHS Trust in central England over a 20-year period from 2000 to 2019.

Babies were stillborn, died shortly after birth or were left severely brain-damaged, according to the review, which was ordered in 2017 after concerns about high rates of neonatal deaths at the hospital group.

It also disclosed that nine of 12 mothers who died during the period could have had “significantly” better treatment, and others were made to have natural births when they should have been offered Caesarean sections.

But the trust, which operates several hospitals and maternity units in the county of Shropshire either failed to investigate sufficiently or learn from the cases.

The report’s author, maternity expert Donna Ockenden, said that meant “the true scale of serious incidents… went unknown over a long period of time”.

Families who pushed for an inquiry after years of campaigning broke into tears after gathering to read the report’s findings.

Kayleigh Griffiths, whose daughter Pippa died in 2016 from a common cause of severe infection in newborns, said the report was a catalogue of “harmed families”.

“It’s really important that maternity services up and down the country read this and listen to what families have gone through and the impact that’s had on people’s lives,” she added.

In parliament, British Health Secretary Sajid Javid apologised.

“The report clearly shows that you were failed by a service that was there to help you and your loved ones to bring life into this world,” he added.

‘Repeated failures’

Charlotte Cheshire said staff dismissed her concerns when her son Adam, now 11, contracted an infection soon after birth. He now has multiple severe health problems.

She said the report should spur maternity safety improvements across the country. “I don’t want any other family to have to go through what we’ve gone through,” she told the BBC.

Javid and the hospital trust promised to implement the report’s dozens of recommendations, acknowledging that the care and even compassion given was not up to standard.

Those responsible for “serious and repeated failures” would be held to account, he vowed, saying a police investigation is looking at some 600 cases.

West Mercia Police said detectives were seeking to determine whether there is evidence to support a criminal case against the trust or any individuals.

Lead investigator Damian Barratt called the probe “highly complex and very sensitive”. “No arrests have been made and no charges have been brought,” he added.

The report outlined how some babies suffered skull fractures, broken bones or developed cerebral palsy after traumatic forceps deliveries.

Other newborns were starved of oxygen and experienced life-changing brain injuries, according to the review of cases involving nearly 1,500 families and nearly 1,600 clinical incidents.

Of the 498 stillbirths examined, it found that one in four had “significant or major concerns” over the maternity care given.

Had the care been managed appropriately, they could have had a different outcome, it added. 40% of the stillbirths were never investigated by the trust.

Ockenden said midwifery staff were “overly confident” in their abilities, were reluctant to involve senior staff, repeatedly failed to monitor babies’ heart rates, and did not use drugs properly in labour.

Caesarean rates were consistently 8-12% below the English average, and staff were determined to keep rates down, despite the risks involved.

Affected families were kept in the dark about reviews of their cases and often treated without compassion and kindness, the 250-page report outlined.

In some cases, some women who died were blamed for their own deaths, while bereaved parents were ignored when they raised concerns.

– © AFP 2022

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