A review of failures at the Shrewsbury and Telford Hospital Trust found that 300 babies had died or suffered a brain injury as a result of poor care. Maternity expert Donna Ockenden, who led the study, warned that mistreatment was still a problem in the trust, despite calling for immediate action after the initial findings in 2020. Systemic issues in the trust had been pointed out by Ms. Ockendenas as early as November 2019 in her interim report, which was revealed by The Independent. But she said maternity staff told her they were still concerned about the level of care today. The families said they had suffered “cruelty beyond comprehension” as their concerns were not addressed and some deaths were not investigated. Health Minister Sajid Javid told the Commons on Wednesday that in one case significant clinical information had been kept in post-it notes, which were then seized by cleaners. The investigation into the cases of 1,486 families, which started in 2017, found:

Trust “threw the blame” on families after the death of their children Care failures were repeated from one incident to another Traumatic forceps deliveries caused skull fractures, broken bones, or the development of cerebral palsy in infants. External actors failed to hold trust and internally trust was not learned from ratings Babies die after women refuse caesarean section because of a culture that wanted natural births

Ms Ockenden, president of the critique, told the Independent she had staff only contacted her on Tuesday to say she was “afraid to speak out” and “afraid of their job”. The president made it clear that there were continuing concerns about trust care despite the initial revision in 2020 calling for action to improve. Ms Ockenden said she was “surprised” that for more than two decades the weaknesses had not been internally challenged by trust and that external healthcare providers had not held it accountable. He made it clear that there were continuing concerns about foster care despite an initial 2020 revision that required improvement, and warned that failures at Shrewsbury could “be replicated elsewhere” outside of maternity services. Donna Ockenden presents her final report (PA) Case studies have revealed more than 200 preventable deaths, including 131 stillbirths and 70 neonatal deaths. There were an additional 29 cases of severe brain damage and 65 cases of cerebral palsy. Nine women were also found to have died after mistakes. The parents failed because of the trust they told the Independent that they had suffered “inhumanity” and “cruelty beyond comprehension”, as they were blamed for the death of their babies. The families say they were not listened to and asked for an independent council to monitor the implementation of the recommendations by the hospitals. Health Minister Sajid Javid said the report was “a disastrous account for empty bedrooms, homeless families and loved ones taken prematurely.” Mr Javid said the actions set by Ms Ockenden would be welcomed and offered assurances that those responsible for the “serious and repeated failures” would be held accountable. Ockenden’s review was first commissioned by former Health Minister Jeremy Hunt in 2017 and initially covered 23 families. In 2019 the Independent revealed that the initial findings of the review had identified more than a dozen women and more than 40 babies died during childbirth. The review has many reports from parents who said women were “blamed” or “held responsible” after women and babies were injured or killed. Mothers affected by scandal hug after release of final report (PA) Richard Stanton and Rhiannon Davies, whose daughter Kate died in March 2009, were one of the key families leading the campaign for justice. According to Ockenden’s final report, two babies died in similar circumstances the year before Kate’s death. Rhiannon Davies said there should be an independent grievance line for staff who can speak and a committee to review each year ‘s progress on the Ockenden report’s recommendations. Kayleigh and Colin Griffiths, who were also at the forefront of criticism, lost their daughter Pippa in 2016. Speaking to The Independent, they said: “They have not listened to us and they have not listened to our trust, and they continue to tell us that they have learned and today they have shown us that although they tell us they have learned, they have implemented all actions and staff. They have not learned and until they do that we will not be satisfied “. Despite warnings from the review presidency about ongoing problems and that it had not implemented all previous recommendations, Trustee Louise Barnett said Wednesday that she had taken all the action requested after the 2020 mid-term report. “We know we still have a long way to go to ensure that we provide the highest possible level of care to the women and families we care for.” Former Health Minister Jeremy Hunt said that because of the “culture of fear in the NHS”, families have been left to fight for justice. Mr Hunt told the Commons: “Today’s report goes beyond my darkest fears when I appointed her Minister of Health in 2016.” The Ockenden Final Review identifies at least eight regulators and external health care providers who have investigated or highlighted care concerns at the Shrewsbury and Telford Hospitals Trust for 20 years. In 2021, a senior NHS commissioner told critics that they were aware of in-service issues from 2013 to 2020, but were reassured of the change and told that “they had limited powers to change things for the better”. Healthwatch England, whose president Sir Robert Francis led the public inquiry into the Mid Staffordshire failures, said the Ockenden report was “another scandal where it is clear that lessons have not been learned from previous failures”. The agency’s national director, Louise Ansari, added: “We also know that obstetric problems do not stop at Shrewsbury Hospital, with research into failures to provide safe care to mothers and babies recently in other parts of the country.”