A leaked internal report into malpractice at the Shrewsbury and Telford Hospital Trust (SATH) has revealed that dozens of mothers and babies died as a result of endemic, avoidable failures across the Trust.
According to The Independent, clinical malpractice at SATH went unchecked for more than 40 years and the resultant deaths mean it is now the biggest maternity scandal in the history of the NHS. At least 42 babies and three mothers died between 1979 and 2017 at SATH, with more than 50 children suffering permanent brain damage because they were deprived of oxygen during birth. There were a further 47 cases of ‘substandard care’.
The Independent go on to explain that more than 600 cases are currently being examined, with deaths and injuries still being reported at the end of 2018 – meaning there are hundreds more to look into. The cause of the clinical failures reported in the documents are extensive. They include a failure to learn from mistakes – meaning many cases are similar in what went wrong during the birth. Plus, substandard follow-up investigations to prevent further injuries.
The report also found that families were treated ‘with a distinct lack of kindness and respect.’ According to the document, some staff referred to deceased babies as ‘it’, with one baby’s body left to decompose for so long the mother was not able to see the child before they were buried.
The ‘toxic’ culture at the Trust made for little improvement when clinical errors were made, with a defensive attitude from staff that resulted in families being lied to about the extent of malpractice and excluded from investigations.
The Independent reports that despite all of this ongoing for so many years, it took the incessant demands of families victim to the Trust for any real intensive investigation into the general malpractice. Reportedly, the Healthcare Commission highlighted concerns about injuries to babies back in 2007, however they had ‘misplaced’ trust in the Trust to make necessary improvements.
It was thanks to the Stanton-Davis family that widespread clinical failures were revealed. In 2009, the family lost their daughter Kate allegedly because midwives failed to monitor her condition, it was later found that Rhiannon Davis – the mother – should not have been on her specific unit because she had a high-risk pregnancy.
The family embarked on what would become a decade spent attempting to expose the malpractice. Frist, they fought for an inquest into their daughter’s death and then, after it was found her death was avoidable, they demanded the NHS re-examine how they investigate such malpractice.
After a number of other reviews that only revealed further horror stories, the most recent report into SATH was ordered by health secretary Jeremy Hunt in 2017.
Across the SATH Trust - which includes the Royal Shrewsbury Hospital, Princess Royal Hospital in Telford, Oswestry Maternity Unit and Wrekin Community Clinic – 4,700 babies are delivered every year.
Their experiences of maternity care should have been the most rewarding of their lives, but instead have often resulted in tragedy
‘These are real accounts about the suffering and grief experienced by individuals and families,’ midwife Donna Ockenden - who led the review - wrote in the report. ‘Their experiences of maternity care should have been anticipated to be some of the most rewarding of their lives, but instead have often resulted in tragedy, that have continued to have long lasting and profound effects, to the current day.
‘As a result of these families coming forward, this review is now one of the largest the NHS has ever conducted into infant and maternal morbidity and mortality in a single service,’ she concluded.
However, in a statement to the Independent, she says the report leaked appears to be a status update from February 2019 – which was not yet meant to be published. As cases are still being investigated, Ockenden said her and her team are still ‘working hard’ to deliver a comprehensive independent report of all areas of serious concern.