'Justice is coming for every baby' in maternity scandal of 200 deaths, families vow

31 March 2022, 00:05 | Updated: 31 March 2022, 08:03

The maternity scandal saw 201 avoidable infant deaths
The maternity scandal saw 201 avoidable infant deaths. Picture: Alamy

By Will Taylor

Families who fell victim to the UK's biggest maternity scandal have vowed "justice is coming for every baby".

Listen to this article

Loading audio...

Their pledge comes after a report found 201 babies and nine mothers could have survived if they received better care.

They instead were the victim of "repeated failures" at Shrewsbury and Telford Hospital NHS Trust, which also left mothers and babies with major injuries, according to findings by an independent inquiry.

The catastrophic problems, which took place over 20 years, saw the trust fail to learn from its own inadequate investigations as babies were stillborn, died shortly after birth or left severely brain damaged.

Sajid Javid said police are now investigating 600 cases related to the scandal.

Read more: Shrewsbury maternity scandal: 'Failing to listen to women led to 201 babies' deaths'

Reverend recounts her heartbreaking experience at Shrewsbury maternity hospital

Reverend Charlotte Cheshire, whose son Adam was left severely disabled following his birth at Shrewsbury maternity hospital, shared her heartbreaking story with LBC's Nick Ferrari at Breakfast.

"Ultimately, unfortunately there were many signs that my son was ill, that there should have been more interventions from the hospital and it didn't happen in time, to avoid him becoming life-threateningly ill," she explained.

Nick asked the reverend whether she was able to make her concerns aware during her time at the hospital.

"When I was discharged, after 18 days, I was told 'I'm sure you're a bit overwhelmed right now, but if you ever want to come back and ask us any questions we can go through your records with you'. And that was it."

Adam arrived 35 hours after Reverend Cheshire's waters first broke, and she says she was sent home on three occassions to wait.

She said what "sticks in her mind" about the care she was provided is that there were "so many opportunities for staff to pick up there was something wrong with Adam".

Julie Rowlings' daughter Olivia died after 23 hours of labour in which a consultant used forceps.

She said of the damning findings in the Ockendon report: "I am emotional today, because obviously Olivia was mentioned in Donna's speech, she's mentioned in the report.

"So I feel like after 20 years, my daughter finally has a voice. The thing I like about this report is it's not recommendations - it has to happen.

"So we need to be on top of it to make sure it happens. For every family out there, every family that's come forward, this is for them. Justice is coming. For every baby, justice is coming."

QC argues against prosecuting anyone from Shrewsbury and Telford trust

"I would like somebody from the trust to sit face to face with me, and talk to me," she added.

"They've never done that. They've apologised, via media, they've apologised to all the families via media, but they've never sat down with the families."

Mr Javid, the health secretary, said all recommendations over the scandal had been accepted and the Government would act swiftly.

"To all the families who have suffered so greatly, I am sorry," he said.

"The report clearly shows that you were failed by a service that was there you help you and your loved ones to bring life into this world.

"We will make the changes that the report says are needed at both a local and national level."

He added: "I'd like to reassure MPs that a number of people who were working at the trust at the time of the incidents have been suspended or struck off from the professional register, and members of senior management have also been removed from their posts."

West Mercia Police launched Operation Lincoln in 2017 to examine evidence that could support a criminal case against the trust.

"This investigation remains ongoing and very much active,” Detective Chief Superintendent Damian Barratt said.

"This is a highly complex and very sensitive investigation that has required us to speak to a large number of people to gather as much information as we can."

The report, led by maternity expert Donna Ockenden, examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents.

It is the largest-ever inquiry into a single service in the history of the health service and has wide-ranging implications for the maternity in the NHS.

Colin and Kayleigh Griffiths, Rhiannon Davies and Richard Stanton with a copy of the Donna Ockenden Independent Review
Colin and Kayleigh Griffiths, Rhiannon Davies and Richard Stanton with a copy of the Donna Ockenden Independent Review. Picture: Alamy

Louise Barnett, chief executive at The Shrewsbury and Telford Hospital NHS Trust, said: "Today's report is deeply distressing, and we offer our wholehearted apologies for the pain and distress caused by our failings as a Trust. 

"We have a duty to ensure that the care we provide is safe, effective, high quality, and delivered always with the needs and choices of women and families at its heart.

"Thanks to the hard work and commitment of my colleagues, we have delivered all of the actions we were asked to lead on following the first Ockenden Report, and we owe it to those families we failed and those we care for today and in the future to continue to make improvements, so we are delivering the best possible care for the communities that we serve."

External bodies were also blamed by the report.

Ms Ockenden said: "Throughout our final report we have highlighted how failures in care were repeated from one incident to the next.

"For example, ineffective monitoring of foetal growth and a culture of reluctance to perform Caesarean sections resulted in many babies dying during birth or shortly after their birth.

"In many cases, mother and babies were left with life-long conditions as a result of their care and treatment."

Chief Executive for The Shrewsbury and Telford Hospital NHS Trust Louise Barnett
Chief Executive for The Shrewsbury and Telford Hospital NHS Trust Louise Barnett. Picture: Alamy

Among the findings, it was revealed that families were locked out of reviews when things went wrong and were often treated without compassion and kindness.

The trust, which is ranked inadequate, was also found to have repeatedly failed to adequately monitor baby's heart rates, with catastrophic results, alongside not using drugs properly in labour.

Ms Ockenden identified nine areas - and 60 actions - for learning and improvement at the trust, including management of patient safety, patient and family involvement in care and investigations, complaints processes, and staffing.

In addition, 15 "immediate and essential actions" for all maternity services in England are put forward, covering 10 key areas, including that NHS England must commit to a long-term investment plan to ensure the "provision of a well-staffed workforce".

The report added that appropriate, minimum staffing levels must be agreed nationally and locally and be adhered to, while there should be a clear escalation policy when staffing levels are not met.

Every trust should also have a patient safety specialist for maternity services, while "meaningful" incident investigations should happen, with proof of learning six months later.