At least 201 babies could live if their care was better, including 131 stillbirths and 70 who died shortly after birth. Nine mothers also died from preventable deaths. In 94 cases, the babies suffered long-term avoidable injuries, including brain damage, due to a lack of oxygen at birth. The Shrewsbury and Telford NHS Trust’s more than two decades-long report on harm prevention to babies and mothers has found that mothers have been blamed for their babies’ deaths. Some families said the mothers were responsible for their own deaths. Read also: Babies who died in the worst maternity scandal in the UK Richard Stanton, whose baby Kate died in the Trust in 2009, told Sky News: “This must be a landmark moment for maternity care across this country that a tragedy of this magnitude can never be allowed to happen. again. “Those in charge of politics must ensure that the policy is implemented and tested to make sure that this never happens again and also that the bereaved parents are not at the forefront of having to reveal such a tragedy.” Image: Rhiannon Davies with daughter Kate Stanton-Davies, whose father Richard says should never happen again The independent review chaired by midwife Donna Ockenden examined 1,592 clinical cases involving 1,486 families. Most of the incidents occurred between 2000 and 2019. Reluctance to perform caesarean sections, failure to assess patients’ risk He found that a culture that favored natural childbirth led to a reluctance to have a caesarean section that resulted in many babies dying. There has been a failure to properly assess patient risk, a failure to properly monitor infants, and a repeated failure to learn from mistakes. Inspection President Donna Ockenden said: “Throughout our final report we have pointed out how care failure has been repeated from one incident to another. “For example, ineffective monitoring of fetal development and reluctance to have a caesarean section result in many babies dying at birth or shortly after birth. “In many cases, mothers and babies have been left with lifelong problems as a result of their care and treatment.” He added: “The reasons for these failures are clear. There was not enough staff, there was a lack of continuing education, there was a lack of effective research and governance in the Trust and a culture of not listening to the families involved. It was the Trust’s tendency to blame mothers for their bad results, in some cases even for their own deaths. “What is surprising is that for more than two decades these issues have not been challenged internally and the Trust has not been held accountable by external bodies. “This underscores the need for systemic change at the local and national levels to ensure that the care provided to families is always professional and compassionate and that teams from department to council are aware of and accountable for the values ​​and standards they must adhere to. “In the future, there can be no excuses. Trust councils must be accountable for the maternity care they provide. To do this, they must understand the complexity of obstetric care and receive the funding they need.” Use the Chrome browser for a more accessible video player 6:01 Stories behind the motherhood scandal A “heartbreaking picture” of repeated failures in care Her report identifies more than 60 areas in which the Shrewsbury and Telford Trust need to take action. The review also outlined 15 areas in which all maternity services in England need to take steps to improve patient safety. Responding to the report, Health Minister Sajid Javid said: “Donna Ockenden’s report presents a tragic and painful picture of repeated failures in care over two decades and I deeply regret all the families who have suffered so much. “Since the publication of the initial report in 2020, we have taken steps to invest in maternity services and increase the workforce and we will make the necessary changes so that no family has to go through this pain again. He added: “I would like to thank Donna Ockenden and her entire team for their work in all this long and painful research, as well as all the families who came forward to tell their stories.”