Medical Negligence

Have failings highlighted in Shrewsbury and Telford maternity deaths scandal been repeated at other Trusts due to NHS targets over ‘natural births’?

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Lauren Dale

Director of Risk & Compliance

6 min read time
30 Mar 2022

The failures in maternity care at Shrewsbury and Telford NHS Trust which have been laid bare by the findings of a five-year inquiry today are simply horrifying.

Significant or major concerns over the maternity care provided were found in 201 deaths – 131 stillbirths and 70 neonatal deaths and 84 brain damage cases between 2000 and 2019.

Dozens more babies also sustained life-changing injuries as a result of the failure to provide adequate treatment. Mothers also died or sustained serious injuries too.

Today, a report said mothers and babies died or suffered major injuries due to “repeated failures” by the trust, which presided over catastrophic failings for 20 years and did not learn from its own inadequate investigations.

It was revealed that an obsession to meet Government targets, and pressure from the NHS to reduce caesarean rates and increase the number of ‘normal births’, was central to a toxic culture developing on maternity wards.

Mothers were routinely overmedicated with drugs to bring on contractions to lead to vaginal birth.  Many were forced to endure traumatic labours, despite having a number of risk factors which were known to midwives and doctors.

Forceps and excessive force were used during delivery which left many newborn babies with fractured skulls and broken bones. Others were starved of oxygen and left with life-changing disabilities. Hundreds were stillborn, died shortly after birth or left permanently brain-damaged.

Whilst I am very saddened to read the details of this report, I have to say I am not shocked.

The reality is, if it wasn’t for this inquiry, this appalling scandal would have been allowed to slip through the net – and perhaps continue – with more families being left with their lives devastated, and believing wrongly that they were the only ones let down.

Initially there were 23 cases of concern highlighted at this Trust.

Then, as details began to emerge, more families came forward and the investigation grew and grew, ending with expert midwife Donna Ockenden and a team of more than 90 midwives and doctors examining 1,862 cases – thought to be the largest ever review of maternity care in the NHS.

This is not the first time, in recent times, that such failings have been exposed in maternity care in our country.

In our work at Hudgell Solicitors we have campaigned repeatedly for increased investment into maternity training and funding alongside the mother and baby charity Baby Lifeline, and with the charity’s ambassador James Titcombe, whose son Joshua died in 2008 after hospital staff failed to pick up on signs of an infection for almost 24 hours.

An investigation into baby deaths at Furness general hospital in Barrow between 2004 and 2013 found a “lethal mix” of failings at almost every level, and that maternity services were beset by a ‘culture of denial, collusion and incompetence’, with ‘an insistence among midwives to pursue normal childbirth “at any cost’.

The problems led to 20 instances of significant or major failures of care at the hospital, associated with three maternal deaths and the deaths of 16 babies at or shortly after birth.

Today’s review findings surely poses the question of what has been happening at other trusts over these past two decades, and should there be inquiries carried out as a matter of course?

Families left to fight for answers and understanding

Today’s report outlines examples of families having to fight for answers – all this after enduring a traumatic ordeal that most of us cannot begin to imagine.

Making families fight for explanations and understanding is simply appalling and should never happen.  They deserve answers at the very least.

The Government strives for a duty of candor, openness and honesty, and whilst some of the examples in this report predate this Government incentive, it is clear that it is not upholding the level of transparency expected or deserved. That is a concern which must be addressed.

Within our work at Hudgell Solicitors we support many families to investigate the medical care provided when a baby dies at birth, and parents have concerns over their treatment during pregnancy and labour. They are almost always told ‘nothing else could have been done’, and sent home without any answers, often left with a feeling that they were in some way to blame.

I have supported many families who felt they had not were not adequately advised during their pregnancies, not informed about the risks of a natural birth or talked through the alternative options.

One mother in particular springs to mind who was a first time mother and expecting a baby that was measuring larger than anticipated.

She had other risk factors including a raised BMI and high blood pressure, however at no time was the higher risk of her baby developing shoulder dystocia (when the baby’s shoulder becomes stuck in the birth canal during delivery) discussed with her and her partner.

Shoulder dystocia can have a life-changing impact, and sadly in this instance, it caused a fatal outcome as her baby passed away prior to delivery due to reduced oxygen levels.

Another mother our firm also supported was not advised of the risks of a natural delivery, even though she should have been considered at greater risk due to having had a traumatic birth with an earlier baby.

Lessons were not learned and her baby suffered life changing injuries, leaving them needing lifelong assistance. It was case which resulted in a lengthy legal battle before the Trust finally admitted their failure to properly advise the mother, and thankfully we were able to pursue damages to help support the family in providing for and raising their child.

Low caesarean section numbers cannot be deemed a ‘success’ and celebrated when they come at the cost of considering the best interests of a mother and baby.

Perhaps the biggest lesson from this shocking scandal is that targets should never be around numbers and statistics related to types of births, but the outcomes of births and whether the best was done for mother and baby.

It is inexcusable to encourage – and take medical decisions which risk injury and life – without giving mothers and their families the full facts with regards to the risk.

This culture should never have been allowed to develop – and the Government must take action now to reassure that it is not prevalent at other trusts across the country now.

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Have failings highlighted in Shrewsbury and Telford maternity deaths scandal been repeated at other Trusts due to NHS targets over ‘natural births’?

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