Report reveals shocking extent of tragedy on NHS trust's maternity wards

A major report into failings in the maternity section of a National Health Service trust in England has found understaffing, a lack of training, and a culture of not listening to families were among factors that contributed to more than 200 deaths and almost 100 long-term injuries to babies and their mothers.

The independent review looked at incidents in the Shrewsbury and Telford NHS Trust in the west of England over a period of more than two decades, from the turn of the millennium onward, and concluded that better care could have helped at least 201 babies to survive, including 131 who were stillborn and 70 who died soon after birth.

It also found that 94 babies were left with avoidable long-term injuries because of a lack of oxygen during their birth, and that nine mothers had died avoidable deaths.

The trust, which has taken full responsibility for the study's findings, was also found to have a culture of not investigating mistakes, with many being "inappropriately downgraded" and inadequate action taken as a consequence.

"Throughout our final report we have highlighted how failures in care were repeated from one incident to the next," said the review's chair, midwife Donna Ockenden.

"In many cases, mothers and babies were left with lifelong conditions as a result of their care and treatment.

"The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved. There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths.

"What is astounding is that for more than two decades, these issues have not been challenged internally and the trust was not held to account by external bodies."

She said the report's findings mean that maternity systems locally and nationally needed to undergo "systemic change" to avoid any repeat, adding "going forward, there can be no excuses, trust boards must be held accountable for the maternity care they provide. To do this, they must understand the complexities of maternity care and they must receive the funding they require".

The inquiry was commissioned by then minister for health Jeremy Hunt in 2017, at a time when there were just 23 cases that were causing concern.

When its findings were finally revealed, he described it as "very, very shocking and sobering reading".

Even as the inquiry was taking place, Hunt told the BBC, staff had found themselves under pressure over the issue of taking part in it.

"Even in this inquiry, doctors, midwives, nurses at Shrewsbury and Telford said they were silenced, they were told that there would be professional consequences if they cooperated with the inquiry and we have to get rid of that blame culture and make it easy for people to speak openly and transparently when something goes wrong," he said.