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Final report on UK maternity scandal that led to 100s of brain-damaged or stillborn babies

Being forced to give birth “naturally” in efforts to suppress Caesarean rates, delays in admitting women to labour wards, repeated failures to adequately monitor babiesʼ heart rates, and not using drugs properly in labour, were just some of the reasons for hundreds of babies dying or suffering brain injury in the UK, reports The Guardian.

The Ockenden Report on the Shrewsbury and Telford hospital NHS trust followed a five-year long independent inquiry into the largest maternity scandal in the history of the National Health Service began with one grieving mother looking for answers and ended up involving 1,486 families and 1,592 clinical incidents.

The distressing story of Shrewsbury and Telford hospital NHS trust, where hundreds of babies died unnecessarily or suffered life-changing injuries, is well known, reports The Guardian, but nevertheless, when the final 234-page report by Donna Ockenden was published last week, many were shocked.

One was former health secretary Jeremy Hunt, who commissioned the inquiry after being approached by a distressed mother and others affected by poor care at Shrewsbury. The report’s findings were “far worse” than he could ever have imagined, he said.

It describes in detail for the first time how 201 babies and nine mothers could have or would have survived if the trust had provided better care.

Ockenden found the trust presided over catastrophic failings for two decades – and did not learn from its own inadequate investigations – which led to more babies being stillborn, dying shortly after birth or being left severely brain damaged.

Some women were forced to have “natural births” despite the fact they should have been offered a Caesarean. Ockenden found that for 20 years the Caesarean section rate at the trust was consistently 8% to 12% below the English average. Incredibly, this was held up nationally as a good thing.

However, the suggestion by some that the focus on “natural births” was the main cause of the scandal is misplaced. The final report makes this clear. Instead, the deadly tragedy at Shrewsbury was the result of a toxic cocktail of issues.

Staff were “overly confident” in their ability to manage complex pregnancies, and there was a culture of “them and us” between midwives and obstetricians, which meant some midwives were scared to involve consultants. Investigators found “repeated failures” to escalate concerns, delays in women being admitted to labour wards, and delays to women being assessed for emergency intervention.

Tragically, many of these issues remain a persistent problem in maternity services across England.

Ockenden raised 15 areas for “immediate and essential action” to improve care and safety in maternity services across England. Areas such as accountability, clinical governance and robust support for families have all been included as “must dos”.

Staffing is a priority. The report said maternity and neonatal services in England required a multi-year settlement from NHS England “to ensure the workforce is enable to deliver consistently safe” care.

However, health leaders told The Guardian that the current shortage of more than 2,000 midwives means that women and babies will, for now, remain at risk of unsafe care.

More widely, the NHS must demonstrate an ability to admit to mistakes and learn from them, and promote a culture of openness.



The Guardian article – Baby deaths inquiry points to issues across England’s maternity services (Open access)


See more from MedicalBrief archives:


Ockenden Report into 'one of the biggest scandals in NHS history'


Natural birth obsession is a ‘tragedy’ for many mothers and their babies


100s more cases emerge in UK's baby deaths scandal


UK report: Dozens of babies died in maternity scandal



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