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16 December 2020 12:39

Shropshire Ludlow Flood warning

Shrewsbury maternity scandal: MPs told of NHS trust's culture of 'normal birth at any cost'

Mothers and fathers caught up in the worst maternity scandal in the history of NHS have a "huge amount of guilt" because they were not able to get the hospitals involved to listen to their complaints, MPs have been told. Donna Ockenden, the midwifery expert leading a review into deaths and brain damage at the Shrewsbury and Telford hospitals (SaTH) told the health select committee that the trust's maternity services had a "focus on normal birth at pretty much any cost", an approach that had tragic consequences. Ockenden's interim report last week into 250 out 1,862 cases under review, found that the rate of C-section births at the trust were significantly below the English and regional average. Speaking to MPs on Tuesday, Ockenden said: "The one issue that stands out above everything else is a failure to listen to families. Asked whether the term "normal birth" should be dropped, Ockenden said: "I've met hundreds of families face to face in Shrewsbury and Telford and the very clear steer from those mothers and their extended families is that they want a birth that is safe.

There was a culture of "normal birth at almost any cost" at a hospital trust being investigated over what could be the biggest maternity scandal in the history of the NHS. Midwife Donna Ockenden, who last week published an independent report on failings at the Shrewsbury and Telford NHS Trust (SaTH), told MPs she had spoken to "hundreds of women who said they felt pressure to have a natural birth". Ms Ockenden, an independent midwife commissioned to review cases in 2017, said her final report into maternity care at the trust will examine why the push for natural birth existed there. Ms Ockenden is examining 1,862 cases where babies or mothers died unnecessarily, or were caused unnecessary harm by maternity care at the trust. She told the Health and Social Care Select Committee that she believed the main reason the scandal went on for so long is a failure of the trust to listen to families.

Sky News has been shown a letter that has been sent to all trusts in England, in which Ms Ockenden outlines the immediate actions required in order to improve safety of maternity services. Ms Davies told Sky News: "There absolutely no commitment within this trust to learn from serious incidents for the prevention of future harm, when learning could occur as a result of a review, all too often the real issues weren't identified or acted upon. Following publication of the Ockenden report on Thursday, Louise Barnett, chief executive at The Shrewsbury and Telford Hospital NHS Trust, said: "I would like to thank Donna Ockenden for this report but more importantly the families for coming forward. An independent review is ongoing into maternity care at the Shrewsbury & Telford Hospital Trust. 'Dismissive' and 'unkind' letters were sent to bereaved families trying to shift blame for the loss of babies at Shropshire's scandal-hit hospital trust, which often failed to investigate until faced with a formal complaint or legal action, MPs have heard.

Donna Ockenden, who is leading an independent review into the Shrewsbury & Telford Hospital Trust (SaTH), gave evidence to the government's Health and Social Care Committee just days after releasing a damning report into the first 250 of 1,862 cases she is looking into. "We know that many, many families tried over many years to try to get the trust structure - and that's midwifery, obstetrics, general management, and to executive level - to listen," she said. The review was triggered by 23 cases compiled by two families - Richard Stanton and Rhiannon Davies, whose daughter Kate died under the care of the trust in 2009, and Kayleigh and Colin Griffiths, whose daughter Pippa died in 2016. Ms Ockenden said her team would be looking at the issue of why SaTH had such low Caesarean section rates in their full report, due out next year. The issue of medical staff listening to mothers and families, and allowing them to be "equal partners" in their care, was one of the key messages to take from the report, she said.

A hospital trust where 42 babies and 13 mothers died in 20 years had a culture of wrongly blaming parents, the former senior midwife leading an inquiry has told MPs today. Shrewsbury and Telford Hospital NHS Trust was condemned in an interim report by Donna Ockenden last week, highlighting a range of failures including not properly listening to parents. Ms Ockenden told the Commons Health and Social Care Committee on Tuesday that there was a 'culture' of blaming mothers and fathers, but also that the trust failed to get to the bottom of why babies died. Discussing the interim report, Ms Ockenden told the committee: 'I think the one issue that stands out above everything else was a failure to listen to families. Shrewsbury and Telford Hospital NHS Trust was condemned in an interim report by Donna Ockenden last week A letter from the Trust to Mrs Jones said that its investigation showed 'that both babies had died from severe hypoxic ischemia (oxygen starvation to the brain) contributed to by delay in recognising deterioration in the foetal heart traces and missed opportunities for earlier delivery.' The midwife came in crying, saying: 'I'm so sorry, I'm so sorry,' Mrs Jones said at the time.

Concluding her evidence, Ms Ockenden added: 'Childbirth and the arrival of a new baby should be the most joyous event in a family's life, and it is simply unacceptable if what we leave along the way are instead broken families and women who carry guilt on their shoulders for many years. Last week, Richard Stanton and Rhiannon Davies, who lost their daughter Kate hours after she was born with anaemia in 2009, said Shrewsbury and Telford Hospital NHS Trust in Shropshire 'should hang their heads in shame' and stop 'victim-blaming'. Their comments came after the release of the review which found women were 'blamed for their loss,' and in other cases families' concerns were 'dismissed or not listened to at all'. Between 2000 and 2019 42 babies and 13 mothers died during or shortly after childbirth at the trust but the inquiry is now examining the cases of 1,862 families. Ms Davies, 46, said she believes the Shrewsbury and Telford Hospital NHS Trust (SaTH) used 'victim-blaming' as a way of distracting attention away from staff failings. Examples of 'shocking failings' at scandal-hit NHS trust The findings of the Ockenden Review have detailed a number of 'shocking' examples of maternity care failings by Shrewsbury and Telford Hospital NHS Trust. A mother whose baby died 17 hours after birth said she and her partner were offered 'no support' and hospital staff were 'lacking in compassion and actually making it so many times worse'. Former health secretary Mr Hunt said the review 'could become the biggest patient safety scandal ever for the NHS,' adding that 'hundreds of precious babies died needlessly.' Describing the conduct of some staff towards grieving families identified by the report, Ms Davies added: 'Victim-blaming, mother-blaming, I think, is a very convenient approach for this hospital trust - they would find any reason to cast doubt on what may have happened. Maternity minister Nadine Dorries criticised Shrewsbury and Telford Hospital Trust for 'shocking failings,' that led to the deaths of newborn babies 'There have also been cases where women and their families raised concerns about their care and were dismissed or not listened to at all.' Commenting on her initial findings, Ms Ockenden said: 'Over the last three years, this independent review team has been listening to and working with families and the trust in order to try and understand what happened. 'Today 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. She said: 'My heartfelt sympathies are with every family who has been affected by the shocking failings in Shrewsbury and Telford Hospital NHS Trust's maternity services. 'I expect the trust to act upon the recommendations immediately, and for the wider maternity service right across the country to consider important actions they can take to improve safety for mothers, babies and families. Louise Barnett, the latest person to take the position Shrewsbury and Telford Hospital NHS Trust, said: 'I would like to thank Donna Ockenden for this report but more importantly the families for coming forward. '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.'