Shrewsbury & Telford Hospital NHS Trust Maternity Care Negligence Claims.

On Monday 11 November 2024, the Trust released a Neonatal Review Report which was prepared by the Royal College of Physicians. The report’s main objective was to provide an independent and expert review of perinatal mortalities, focusing on two consecutive years, 2021 and 2022. The Shrewsbury and Telford Hospital NHS Trust (“the Trust”) and the West Midlands as a whole, has the highest infant mortality in England and the hope was that the report would identify the cause of this and propose changes necessary to reduce neonatal mortality.

The report examined 18 neonatal deaths and graded their care. Whilst there were some examples of excellent and good care, the vast majority experience poor care (graded either “room for improvement” or “unsatisfactory”). The failures identified largely reflect those already recognised by the Donna Ockenden Review in 2020 so this report is seen by many as a painful reminder that more needs to be done at this Trust to ensure the care provided is safe.

Whilst the report does not find the root cause of the higher mortality rate, it does make recommendations and provides timelines for implementation. It will be interesting to see how these are implemented and whether the Trust can provide an update on progress in the next few months.

Laura Weir, partner has spoken to ITV News and BBC News about this latest report and hopes to encourage the Trust to continue to investigate, implement recommendations, learn and improve.

In the meantime, we will continue to represent and support families impacted by maternity and neonatal failures at the Trust, three of which feature in this latest report.

Amy Bills has written a blog explaining about the report which can be viewed here.

The Trust has revealed that it instructed the Royal College of Physicians to undertake a review into neonatal deaths at the Trust in 2021 and 2022 in an attempt to identify why The Shrewsbury and Telford Hospitals NHS Trust has higher than National average neonatal deaths each year. The Trust intends on sharing the report and findings on 11 November 2024 and this will be discussed at the next Public Trust Board meeting which is due to take place on 14 November 2024. It is anticipated that failures in care will be identified, which will undoubtedly shake the local community again. We will update once this latest report has been made public and we will continue to be available to support the families impacted.

The final report which was published on 30 March 2022 has reviewed the maternity care received by 1,486 different families, involving 1,592 clinical incidents. Cases span from as early as 1973, with the latest in 2020. As such, it is the largest ever number of clinical reviews conducted as part of an inquiry relating to a single service in the history of the NHS.

The report highlights woefully poor practice over a period of decades, to include a reluctance to carry out caesarean sections, a failure to train staff properly to read CTG (heart monitoring) traces; inadequate team working, a refusal to follow national guidelines, an inability to learn from mistakes and a culture of cover-up. It has been identified that there are 60 areas where improvements could be made at The Shrewsbury and Telford Hospital NHS Trust.

Harrowingly, the report identifies 201 cases of still birth and neonatal deaths that could have been avoided if better care had been provided and nine avoidable maternal deaths. Other babies were starved of oxygen and left with life-changing disabilities. It was found that false reassurances were given to families about the maternity services despite repeated concerns being raised.

We have profound sympathy for all of the families who have suffered indescribable loss and harm as a result of maternity failings at The Shrewsbury and Telford Hospital NHS Trust and we hope that this report will herald the improvements in maternity care that they have been asking for.

We will now continue to support the families we represent as we navigate the next stage of this process.

Read about the report in Emma Farrington’s blog here

At 9pm on Wednesday 23 February 2022, a BBC Panorama documentary will be aired focusing on maternity care in Shropshire. The programme will feature an interview with our Head of Clinical Negligence and partner, Beth Heath as we continue to represent families seeking justice from one of the biggest scandals in the history of the NHS.

Ahead of this programme, BBC News published an informative and emotive article summarising the position as it stands. This is examined and summarised by Laura Weir, associate solicitor here in a blog.

Listen here to a podcast recorded by Beth Heath, Head of Department. In this episode, Beth looks at the maternity claims at SaTH and the report which is due from Donna Ockenden. She also discusses the three reoccurring themes which are regularly presented to her.

Donna Ockenden confirmed that her second and final report out of the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust was due to be published on 22 March 2022, but this was postponed. It was then confirmed the report would be released on 30 March 2022. This report will build upon the work of the first report to ensure the Local Actions for Learning and Immediate and Essential Actions are strengthened and implemented at the Trust and across the wider maternity system in England. This report was eagerly awaited by the families we represent.

On 10 December 2020, Donna Ockenden released her first report on the emerging findings and recommendations out of the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust. The first report focuses on 250 maternity cases and provides essential recommendations that require immediate action for both the Shrewsbury and Telford Hospital NHS Trust and maternity services across the NHS as a whole.

The findings of the report identified worrying trends at the Trust, in particular during the last two decades.

The report identified that one of the most disappointing themes was the reported lack of kindness and compassion from the maternity and bereavement services at what was such a difficult time for families.

Failings were identified in relation to appropriately risk assessing pregnancies and adequately explaining to prospective parents the risks and options for delivery in obstetric units and the standalone maternity units in the Trust’s geographical area.

The first report of the review found that there was a significant number of cases where midwives and obstetricians did not demonstrate an appropriate level of competence in relation to the monitoring of the fetal heart rate and augmentation of labour with the use of oxytocin.

There was evidence of cases where there were repeated attempts at vaginal delivery with forceps causing damage to both mother and baby and a feeling from parents that the Trust was trying to keep the caesarean section rate, already lower than the national average, down.

The report made seven essential recommendations:

• Strengthen maternity units by increasing partnerships between trusts and local networks.
• Women and their families are listened to with their voices heard.
• Staff who work together must train together.
• Robust pathways must be in place to manage complex pregnancies.
• Women must undergo a risk assessment at each contact throughout their pregnancy pathway.
• All maternity services must appoint a dedicated lead midwife and lead obstetrician to champion best practice in fetal monitoring.
• Women must have access to accurate information to enable informed choice about place of birth and mode of delivery including choice for a C-section.

It is understood that Donna Ockenden initially intended to release the final report on 22 March 2022 but this was postponed. The report was released on 30 March 2022.

Since the release of Donna Ockenden’s emerging findings report, there have been a number of other developments. A police investigation is underway looking into allegations of corporate manslaughter and gross negligence manslaughter, known as Operation Lincoln.

Announcements have also been made to confirm that additional funding will be made available to improve maternity services and training across the NHS.