A devastating report into maternity services at the Shrewsbury and Telford NHS Trust found that the deaths of 201 babies and nine mothers could have been prevented if the trust had provided better care. But midwives warn that many problems in the report are endemic across the UK.
Content warning: this article contains descriptions of neonatal death that readers may find upsetting.
Women are still reeling after a major report released last week revealed the life-altering harms and tragic deaths of mothers and babies at the Shrewsbury and Telford NHS Trust.
Senior midwife Donna Ockenden spent five years analysing the experiences of 1,486 families under the care of the trust from 2000 to 2019. Her review examined the causes of stillbirths, neonatal baby deaths, deaths of mothers, babies born with disabilities due to poor care and failures leading to mothers’ injuries. It concluded that around 201 babies and nine mothers could have survived if the NHS trust had provided better care.
Failure to properly assess risk, listen to families, monitor babies and learn from mistakes were all discovered within the lengthy investigation and external bodies were blamed for neglecting to improve the maternity services within the trust. It was a ‘perfect storm of failure’ that led to the worst scandal in NHS history.
Rhiannon Davies is one of the people who has fought for years for a full inquiry into the failings at the Shropshire trust. Davies was due to give birth to her first child in 2009 when she raised concerns about reduced movements in the last weeks of her pregnancy. She was reassured she was a low-risk pregnancy and could still give birth in a midwifery-led unit – a place not fully equipped to help very unwell children. After her daughter, Kate, was born, warning signs of a group B streptococcus infection weren’t picked up and Kate died 31 hours after being born.
Kayleigh Griffiths has also been among those campaigning for a wider inquiry into maternity care in Shropshire. Her daughter Pippa was born at home in 2016 following a straightforward pregnancy. She struggled to feed, but when Griffiths phoned midwives, she was told everything was fine. That night, Pippa developed noisy breathing and then vomited brown mucus. Still, Griffiths was reassured by the midwives. The next day, Pippa died.
The accounts in the report go on and on, with stories of babies and mothers lost or injured from “failures in care” and “ineffective monitoring of foetal growth and a culture of reluctance to perform Caesarean sections.” Lives that could have been saved with more attentive care.
While this particular trust has come under scrutiny after the Ockenden report’s shocking findings, maternity scandals are not new to the NHS, raising the question of whether it is safe to give birth in NHS hospitals. Ockenden has said pregnant women will not be safe to give birth in England until the essential actions in her report are implemented. Can women trust they will be listened to during pregnancy and childbirth? Can families confidently put the lives of their babies into the hands of midwives and doctors?
In a recent interview on BBC Woman’s Hour, Emma Barnett challenged Maria Caulfield, minister for patient safety and primary care, on the fact that only 1% of maternity services in England are rated as outstanding. “If we only had 1% of schools at that standing in this country, there would of course be cause for concern,” Barnett probed.
Caulfield assured listeners with statistics about improvements in services since Ockenden’s interim report was published in 2020 and spoke about the commitment to improve services further following the scandal at Shrewsbury and Telford.
“Many of the problems in the report are endemic across the UK, such as short staffing and midwives fearful of raising concerns,” veteran NHS midwife and author Leah Hazard tells Stylist. “But I would like to emphasise that the vast majority of midwives are trying harder than ever to provide gold-standard care in incredibly difficult circumstances. We have been begging for better resources and a systemic overhaul for years. It’s just absolutely awful that it’s taken the deaths of so many women and babies for the government to take notice.”
Near the end of last year, the Royal College of Midwives (RCM) warned of a mass exodus of midwives from maternity care, finding that 67% were not satisfied with the quality of care they were able to deliver due to understaffing. “Without adequate numbers of staff, we are fighting a losing battle,” Gill Walton, RCM’s general secretary said in a press release last October. “Quite rightly, there is a strong focus on improving maternity safety, but there is a risk that the government is ignoring the essential ingredient to that: having the right staff, in the right place.”
For years, maternity services have called on the government for a seismic cultural shift within the NHS to improve maternity safety. Unfortunately, it took a deadly scandal to trigger action from people in power. All eyes are now on the government, watching to see what they will do to rectify their past disregard for the care of women and children’s safety at the most vulnerable time of their lives.
Ockenden has clearly listed 15 immediate and essential actions needed to improve maternity services in England to prevent similar scandals in the future. Sajid Javid, the health and social care secretary, has accepted all the recommended actions from the report and promised to take the findings of the report seriously, starting with an announcement of a £127 million maternity boost for patients and families.
“This is less than half of what the Select Committee recommended for maternity services last summer,” Hazard says, commenting on how the promised amount will continue to fall short to keep babies and mothers safe.
This is a pivotal moment for change within maternity services. A chance for the government to protect the most vulnerable in our society by listening to what midwives have been requesting for years – better resources and systemic improvement.