Shrewsbury & Telford Hospitals NHS Investigation

Tuesday 3rd December 2019

There are reports of a significant number of families across Shropshire being affected by poor care from the maternity services at the Shrewsbury and Telford Hospital NHS Trust. Hundreds of families whose babies died or were left disabled have made contact with a midwife tasked with investigating concerns into maternity services at the Trust.

What went wrong?

Concerns about the standard of care at Shrewsbury and Telford Hospitals started to come to the attention of the media in 2017, when the then Health Secretary announced an investigation into the deaths of 23 babies, that were thought could have been avoided with better care. The number of cases being looked at doubled in August 2018, and has spiralled ever since then.

Complaints were made about medical staff failing to monitor foetal heart rates, and about delays in the deliveries of babies. In November 2019 a report was leaked to The Independent newspaper, detailing how hundreds of births were now being reviewed. Further concerns were raised in the leaked report, including a lack of proper investigations and a failure to learn from mistakes; the same mistakes were repeatedly made. The report covers a period of 40 years, a scale which has led to some classing this incident as one of the biggest scandals in the history of the NHS. The report also highlighted a complete lack of empathy in some of the cases being reviewed:

– Referring to deceased babies as ‘it’

– Getting children’s names wrong

– Telling parents that their case was ‘one of a kind’;

– Allowing a baby’s body to decompose over a period of weeks after a post-mortem, to the extent that the parents could not see their child before the burial.

The report also criticises the Trust for not properly consenting mothers for their method of delivery. There seems to have been a paternalistic approach employed by clinicians whereby they would persuade mothers to have vaginal births rather than caesarean sections, even in cases where a caesarean section would have been a safer option.

Why did things go so wrong?

Until the full report is released, it’s difficult to say. The lack of any learning or understanding of the scale of these problems will no doubt have led to the scandal being much larger than necessary. Problems at the Trust span 40 years; a proper system of learning and reflection would surely have helped reduce the number of people affected at the Trust.

Another common theme, which will have contributed to the scale of the problems, is a lack of adequate communication. Families were either ill-informed (being told that their case was ‘one of a kind’) or not informed at all (one father had feedback on his daughter’s death after bumping into a hospital employee at a supermarket). The very fact that the initial report was limited to just 23 cases, and is now into the hundreds, is evidence of the Trust failing to properly communicate and document families’ concerns.

What is being done about it?

The initial investigation in 2017 was assigned to Donna Ockenden, an independent midwife. She has since added various team members to assist, including an anaesthetist, infection prevention, an ambulance expert, two paediatrician and a physician as well as a number of midwives, neonatologists and obstetricians. She has not yet confirmed when she expects to be able to release her final report but this is somewhat understandable given the ongoing increase in cases. The West Mercia Police are also liaising with Ms Ockenden with a view to considering criminal proceedings once they have had chance to review the final report.

The Trust’s Interim Chief Executive, Paula Clark, has apologised to those affected and said that changes were already being made to their maternity services ahead of the final report being released. This is a proactive approach that perhaps would have helped prevent this if the same attitude had been adopted 40 years ago.

The CQC have visited the Trust, and carried out a three-day (pre-planned) visit in November 2019. A number of good areas of practice were identified, but a number of areas requiring further improvement were also highlighted. This isn’t good given that the Trust have been aware of the investigation for more than two years; evidence perhaps of the huge amount of work needed just to get the maternity services up to a reasonable standard.

Is there a time limit for bringing legal action?

There are time limits which apply to starting Court action, although the time limit depends on the circumstances of your case. With cases involving Shrewsbury and Telford Hospitals Trust, we recommend that you contact one of our specialist solicitors for advice if you’re unsure about whether you still have time to look into what’s happened, as there may be different time limits which apply.

How can I get help if I have been affected by Shrewsbury & Telford Hospitals Trust?

In the first instance, we recommend making contact with Donna Ockenden, the midwife in charge of the inquiry into what has happened. We are happy to assist you with this, and to provide you with legal advice about your rights and about the next steps to take. You may want legal advice if a child has passed away, if a child has been left disabled as a result of poor care, or if someone has been affected in some other way by what has happened.

We appreciate that money cannot change what has already happened, but we can help ensure changes are made to stop this from happening to others, and to look for answers to your questions and help find out exactly what went wrong in your case.

If you would like legal advice about the Shrewsbury and Telford Hospital NHS Trust, please click here to contact one of our specialist medical negligence lawyers, or to request a call back.