Bernie Bentick has been an obstetrician at the Shrewsbury and Telford NHS Trust for almost 30 years. This week, an independent survey will reveal the full extent of the Trust’s failures. It has already been recognized as the worst motherhood scandal in NHS history. “In Shrewsbury and Telford there was a climate of fear where staff felt unable to speak because of the risk of victimization,” Mr Bentick said. “Clearly, when a baby or a mother dies, it is extremely traumatic for everyone involved. “Unfortunately, the mechanisms to try to prevent recurrence were not sufficient for various factors. “The resources and the institutionalized culture of bullying and accusations were a big part of that.” Image: Bernie Bentick was an obstetrician at the Shrewsbury and Telford NHS Trust More than 1,800 avoidable damage cases have been investigated by research. Most occurred between 2000 and 2019. Mr Bentick worked at the Trust until 2020. He said that from 2009 onwards, he expressed concerns to managers. “I think there were important issues that promoted the risk, mainly due to understaffing and culture,” he said. He also accuses hospital bosses of prioritizing the activity – the number of patients attending and the procedures performed – over patient safety. “I believe senior executives were primarily concerned with the activity rather than security – and until security is at the same level as clinical activity, I do not see how the situation will be resolved,” he said. In 2017, independent midwife Donna Ockenden was called by then-Health Minister Jeremy Hunt to investigate 23 cases of concern at the Trust. Since then, hundreds of other families have appeared. A total of 1,862 cases have been investigated since the investigation. The long-awaited report will be published on Wednesday. Use the Chrome browser for a more accessible video player 1:35 2020: Review of infant deaths ‘heartbreaking but powerful’ Ms Ockenden published her interim findings in December 2020. This report highlighted a culture in the Trust of keeping cesarean section rates low. It was found that in some isolated cases, earlier caesarean section would have avoided death and injury. The report also found recurring cases where babies were not monitored properly. The concerns expressed by the families were ignored and there was a lack of kindness and compassion from the staff. Among the cases investigated was the death of Manpreet Uppal. It should be 19 now. Instead, his mother, Kamaljit, still holds the unbearable baby clothes she bought him. He died two hours after his birth. Picture: Kamaljit Uppal is still holding the unbearable baby clothes she bought for her son “There were no regrets” Mrs Uppal vividly remembers the day she was admitted to the hospital for childbirth. “The first thing I said at the door was that I would like to have a C section,” he said. “I prefer part C because the baby’s panties and the doctor came back and said, ‘No, you’re fine. Just keep giving birth. “ “And then he got stuck. One doctor pushed him while the other doctor pulled them, and so they pulled him back doing a C section at the end. But it was too late, unfortunately. “A lot of floppy disks came out. That was it. They never told me anything in detail until I saw my records.” Months later, there was a devastating meeting with a counselor. “He said he got the wrong delivery option,” he said. “It even gave me time that if he had been born in the early hours of the morning, at four past four, the baby would have lived a normal life. “She turned around and said bluntly, ‘If in your position I can get over this pregnancy, get pregnant again and you will get over it.’ “There was no remorse.” Image: Shrewsbury and Telford NHS Trust was home to the worst maternity scandal in the NHS “I look at my beautiful girl and I miss her” Six years later, as Richard Stanton and Rhiannon Davies were getting ready to welcome their firstborn Kate, mistakes would be made again. The staff failed to recognize that Kate was seriously ill until it was too late. “At just over six hours old, Kate died in my arms,” ​​Stanton said. “I think for me, the main memory I have from that day is that Rhiannon arrives at the newborn unit and hears her crying. “Rhiannon knew, I think, inside that Kate was already dead.” Rhiannon treasures a photo of newborn Kate lying in the cradle. “I’m just looking at my beautiful girl and I miss her,” he said. “There were so many mistakes made during my pregnancy, during my birth, in the first hours of her life, so many mistakes. Kate’s death was completely inevitable. That’s the point.” Picture: Rhiannon Davies, Richard Stanton and baby Kate “Make sure this never happens again” A spokesman for The Shrewsbury and Telford Hospital NHS Trust said: “As a Trust we take full responsibility for the failure of our Obstetrics and Gynecology standards and sincerely apologize for all the distress and shock we know it caused. “We have made significant progress in improving the quality and safety of the care we provide, including important work to promote an open and honest culture in the Trust, with expanded and enhanced avenues for colleagues to express concerns and be fully investigated and then and is addressed “. Mr Stanton and Ms Davies say the publication of the fully independent survey should lead to improved maternity care across the country. They have fought tirelessly since Kate died and believe that they should not have pushed so hard to get answers. Mr Stanton said policymakers “must ensure that this never happens again and also that grieving parents are not at the forefront of having to reveal such a tragedy”.