Inquiry to report early findings next month

Parents who lost babies as a result of avoidable errors at the trust have told The Independent they are disappointed in the lack of action from government on improving safety in maternity units across the NHS.

In the last 12 months there have been multiple scandals at hospitals across England with the care regulator the Care Quality Commission warning too many maternity units are unsafe and not doing enough to improve.

Initial findings and urgent recommendations from an inquiry into the largest maternity scandal in NHS history will be published next month, The Independent has learned.

A year on from when The Independent first revealed the scale of the care disaster at the Shrewsbury and Telford Hospital Trust, the independent investigation into 1,862 cases will deliver emerging findings from the first 250 cases.

This will include essential safety recommendations for the scandal-hit trust which has faced mounting concerns over its wider safety and quality of care in the last 12 months.

Midwifery expert Donna Ockenden is leading the inquiry into the Shrewsbury and Telford Hospital Trust which is also facing a police investigation into the dozens of baby deaths and brain damaged children over several decades.

A leaked internal report last year revealed widespread failings at the trust with repeated errors as a result of not learning from mistakes which led to at least 42 babies and three mothers dying between 1979 and 2017.

More than 50 children also suffered permanent brain damage after being deprived of oxygen during birth, the investigation discovered, as well as identifying 47 other cases of substandard care.

Since then the number of cases under investigation has more than doubled to 1,862.

Now the inquiry team are preparing to publish their first report on the 10 December looking at the first 250 cases. This will include the original 23 families that led to the investigation being called by former health secretary Jeremy Hunt. It was later widened after concerns over many more deaths and injuries.

Details of the report have not been announced but it is expected to include essential safety actions for the Shrewsbury trust to take to ensure maternity services are safe.

Investigations into the hundreds of other cases and specific findings in individual cases is likely to take until next year to complete.

The Independent joined with the charity Baby Lifeline to call on ministers to invest in a new maternity safety training fund for the NHS – a call backed by multiple organisations, including the Royal College of Midwives and Royal College of Obstetricians and Gynaecologists and former health secretary Jeremy Hunt.

The original maternity safety training fund cost just £8m to train 30,000 NHS staff but was scrapped after one year despite a positive evaluation. In July The Independent reported on a single clinical negligence claim for a baby disabled by being starved of oxygen during his birth which cost the NHS £37m.

Rhiannon Davies, whose daughter Kate Stanton-Davies died as a result of avoidable errors in 2009 and who helped expose the failures at the trust, told The Independent: “We are really encouraged that Donna Ockenden’s team are producing this report and making what will be essential recommendations for the trust. We’ve heard many times that lessons will be learned but now these are essential actions they must take.

“None of the other families’ voices have been forgotten they will form part of the full report next year. But I do think it is the right thing to do now to make the essential actions public so they can be addresses as soon as possible.

“We need these changes hammered into the culture at that trust so this is embedded and it’s not just Shrewsbury, other hospitals need to look at this and use it in their own cultural journeys.”

Asked about the failure of the government to act on maternity safety she said: “This is a national tragedy playing out on a month by month basis and no one in government seems to actually care. I don’t think anyone has got their eye on maternity safety.

“It is unforgivable that they have not invested in better maternity safety training. From the perspective of preventing harm and saving lives as well as a cost saving. There is no urgency.”

She said health secretary Matt Hancock had been silent on the issue and warned ministers could not use coronavirus as an excuse for inaction: “We were calling for this months before anyone had heard of Covid. They need to show some leadership, they cant just sit and wait for recommendations.”

Kayleigh Griffiths, whose daughter Pippa died after midwives failed to recognise a deadly infection, said the report and its recommendations were a long time coming.

“The frustration for us as we have said all along is that we have recognised what the trouble is but there has never been any action.

“I hope the trust give families an opportunity to see how they are progressing on the recommendations and the opportunity to challenge them over whether they have been implemented properly. It needs monitoring.

“There has to be a change. It is really important that other NHS trusts read this report and they look at their own services and how they can change as a result.

“It’s hugely disappointing. They need to overhaul training and introduce safety training for all maternity staff.

“Maternity safety training is a small investment against the huge costs of negligence claims and they are letting that carry on.”

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