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December 11th 2020

Medical Negligence

Initial findings of Shrewsbury and Telford Hospital Maternity Inquiry are truly scandalous

Amanda Stevens

Amanda Stevens

Managing Director, London and South

Initial findings of Shrewsbury and Telford Hospital Maternity Inquiry are truly scandalous

The initial findings of the inquiry into maternity services at Shrewsbury and Telford Hospital NHS Trust are truly scandalous and also heart-breaking in the way they describe the treatment and attitude towards patients.

The initial findings of the inquiry into maternity services at Shrewsbury and Telford Hospital NHS Trust are truly scandalous and also heart-breaking in the way they describe the treatment and attitude towards patients.

It has been revealed that mothers have in the past been made to feel at fault for the deaths of their babies, and that in many cases deaths have not been investigated to consider possible failings by maternity staff, and ensure vital lessons were learned.

Such has been the scale of the failings uncovered, the initial report lists 27 actions which it says the Trust must now immediately carry out to improve its care for patients.

Seven ‘immediate and essential’ actions have also been made for all maternity services across England to implement, including Trusts working together to investigate serious incidents and ensure learning is shared regionally in a timely manner.

The review, which is looking into 1,862 cases and has initially examined 250 between 2000 and 2018, has highlighted numerous traumatic birth experiences including the deaths of babies due to excessive force of forceps and stillbirths that could have been avoided.

Repeated failures by staff to recognise mothers and babies in deteriorating conditions have also been highlighted, as has a disproportionately high rate of maternal deaths at the Trust.

The report says that whilst women were often correctly identified as being ‘high risk’ due to existing medical conditions, little concrete action appeared to follow with junior doctors conducting assessments and no team working to ensure best care.

Families often feel guilt when errors were in fact made by maternity staff

In our work at Hudgell Solicitors we sadly find ourselves supporting many families who have suffered as a result of similar failings on maternity wards to those highlighted in this report.

We know how such mistakes forever change lives, whether that be by causing serious injuries to babies, or avoidable deaths of mothers and their children.

Many mothers whose children die during pregnancy or birth often express private feelings to our legal specialists of guilt that they were unable to protect their child from harm. This is despite them being under professional clinical care at the time and in a position of trust and dependency on the skills of others, and not in control themselves.

These are feelings which are often only ever lessened following full and thorough investigations, as this can demonstrate that they could never have changed the situation themselves.

It is only right that maternity deaths and serious injuries are appropriately investigated, so to hear of health trusts sending letters ‘focused on blaming the mothers” rather than considering their own potential failings, and a ‘lack of kindness and compassion from some members of the maternity team’ is truly appalling.

Investigations often highlight serious failings by health trusts in the care of mothers and babies, and sadly it is not a surprise to hear that at Shrewsbury and Telford Hospital NHS Trust, many deaths were not investigated as they should have been.

Indeed, our clients often tell us we are the first people to have truly listened to their concerns when they raise questions relating to the loss of a baby. Trusts often leave them feeling nothing else could have been done, when the reality is there have been serious failings in care.

Donna Ockenden, chair of the review, said: “What is very clear from these reviews and conversations is that for far too long women and families who have accessed maternity care at Shrewsbury and Telford Hospital NHS Trust have been denied the opportunity to voice their concerns about the quality of care they have received.

“Many have experienced life changing events which has caused untold pain and distress, including sadly the deaths of mothers and babies; babies who have suffered lifelong health complications as a result of brain damage at or around the time of birth; whole families including mothers, fathers, brothers, sisters and grandparents who have been left utterly bereft.

“Many families have suffered with long-term mental health problems because of their experience of maternity care at the trust and families have expressed their suffering has been made worse as a result of the handling of these incidents by the trust.”

This is a truly shocking summary of maternity care at this trust, but worryingly, one we see replicated on other wards across country, if not on the same scale.

We welcome the fact that this review has not only recommended such a significant list of actions at this individual trust, but also nationally. It perhaps indicates a feeling that this Trust is not alone in failing parents on maternity wards too often.

Reducing the number of birth injuries and death across England’s maternity wards is one of the biggest challenges facing the NHS, and must be a priority, as it is one of the most devastating events any family can suffer.

The report by the inquiry team is expected next year.

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