The review began in 2018, after two families who had lost their babies under the care of Shrewsbury and the Telford NHS Trust in the west of England launched a search campaign.
Former midwife Donna Ockenden led an investigation into nearly 1,600 cases between 2000 and 2019, including stillbirths, neonatal deaths, maternal deaths and other serious complications in mothers and infants.
The study found that 131 stillbirths, 70 infant deaths and nine maternal deaths could or could have been avoided with better care.
Ockenden said Wednesday that the hospital’s management “failed to investigate, failed to learn and failed to improve.”
“This has resulted in tragedies and life-changing events for so many of our families,” he said.
Health Minister Sajid Javid said Ockenden’s report revealed “a tragic and painful picture of recurring care failures”, including a case where “important clinical information was kept in post-it notes” that were wiped clean by trash cleaners, “with tragic for a newborn baby and his family “.
“I’m sorry for all the families who have suffered so much,” Javid said.
He told mourning families that people would be held accountable, saying some staff had been fired or banned from practicing the profession and police were investigating 600 cases.
Ockenden’s initial report in 2020 found that a pattern of failure and poor maternal care led to preventable deaths and injuries to mothers and infants. He said deaths are often not investigated and grieving mothers are sometimes blamed for their loss.
Ockenden said the hospital’s confidence was focused on keeping caesarean section rates low and that in some cases choosing an earlier caesarean section would have avoided death and injury.
Ockenden said Wednesday she was “deeply concerned” that families continued to contact the review team in 2020 and 2021 with concerns about the safety of hospital care.
Ockenden said there had been some progress since its 2020 report, but needed “systemic” improvement across the country, including ensuring proper staffing and funding for maternity wards.
Shrewsbury and Telford NHS Trust CEO Louise Barnett apologized “wholeheartedly.”
He said: “We owe it to those families who failed and to those we care about today and in the future to continue to make improvements.”
Julie Rowlings, whose daughter Olivia died shortly after her birth in 2002, welcomed the strong conclusions of the report.
“I feel that after 20 years, my daughter finally has a voice,” he said.
“For every family out there, every family that has come forward, this is for them. Justice is coming. For every baby, justice is coming.”
