Babies and mothers died amid 'toxic' culture at NHS trust

The 'toxic' culture at an NHS hospital trust led to the death of babies and mothers, a leaked report has revealed.

In what is likely to be the NHS's worst ever maternity scandal, mothers and babies suffered avoidable deaths after major failings stretching back 40 years at Shrewsbury and Telford Hospital.

Children were also left with permanent disability amid substandard care while staff routinely dismissed parents' concerns, were unkind and, in one instance, referred to a baby who died as "it".

In another case, parents were not told their baby's body had arrived back from the post-mortem examination, and it was left to decompose so badly that the family never got to say a final goodbye.

The interim update report, which has been obtained by The Independent, comes from an independent inquiry ordered by the Government in July 2017.

The study warns that, even to the present day, lessons are not being learned and staff at the trust are uncommunicative with families.

It also points to an inadequate review carried out by the Royal College of Obstetricians and Gynaecologists (RCOG) in 2017 and the "misplaced" optimism of the regulator in charge in 2007.

The inquiry, which is being led by maternity expert Donna Ockenden, was launched by former health secretary Jeremy Hunt.

Its initial scope was to examine 23 cases but this has now grown to more than 270 covering the period 1979 to the present day.

The cases include 22 stillbirths, three deaths during pregnancy, 17 deaths of babies after birth, three deaths of mothers, 47 cases of substandard care and 51 cases of cerebral palsy or brain damage.

The interim report written by Ms Ockenden for NHS Improvement and the trust details the pain suffered by the families.

The inquiry was launched following the efforts of Rhiannon and Richard Stanton Davies, whose daughter Kate died shortly after birth in 2009, and Kayleigh and Colin Griffiths, whose daughter Pippa died shortly after birth in 2016.

The interim report points to:

- Babies left brain-damaged because staff failed to realise or act upon signs that labour was going wrong.

- A failure to adequately monitor heartbeats during labour or assess risks during pregnancy, resulting in the deaths of some children.

- Babies left brain-damaged from group B strep or meningitis that can often be treated by antibiotics.

- A baby whose death from group B strep could have been prevented after its parents contacted the trust on several occasions worried about their newborn baby.

- Many families "struggling" to get answers from the trust around "very serious clinical incidents" for many years and continuing to the present day.

- One father whose only feedback following his daughter's death was when he bumped into a hospital employee in Asda.

- One parent reporting a "closed culture" at the trust over hospital fears of being sued.

- Families who told how "the trust made mistakes with their baby's name and on occasions referred to a deceased baby as 'it"'.

Ms Davies told The Independent the leaked report showed the trust's chronic inability to learn from past mistakes had "condemned my daughter to death", adding: "How has this been tolerated for so long? It is horrific."

In the report, Mrs Ockenden wrote: "No apology will be sufficient or adequate for families who lost loved ones to avoidable deaths, or whose experience of becoming a parent was blighted by poor care and avoidable harm.

"Many families have described to me how they live on a daily basis with the results of that poor care."

The report also criticised the trust's slow response in sending the inquiry medical records, clinical notes and other documents.

Until now, Morecambe Bay, which saw the avoidable deaths of 11 babies and one mother at Cumbria's Furness General Hospital between 2004 and 2013, was the worst ever maternity scandal in the history of the NHS.

Bill Kirkup, who chaired the Morecambe Bay inquiry, told The Independent the interim review made for "ghastly" reading and showed "unmistakeable parallels" with the scandal at Morecambe.

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