Over decades, the Shropshire trust failed to properly investigate incidents of poor care by its staff with mistakes being repeated, according to the independent inquiry which is investigating more than 1,860 cases of poor care.
More than a dozen women and more than 40 babies died during childbirth at Shrewsbury and Telford Hospital Trust because of a culture that denied women choice and subjected hundreds of families to unsafe care, an official report into the NHS’s largest maternity scandal has found.
In some cases women had been medicated and forced to undergo traumatic forceps deliveries – leaving babies with fractured skulls and broken bones – because of a culture of trying to avoid deliveries by caesarean section.
The Independent last year revealed a leaked report from the inquiry that described more than 40 baby deaths and more than 50 children suffering brain damage at the trust, but since then the number of families complaining of poor care has more than doubled.
A majority of incidents examined by the inquiry happened during the past 20 years, it said, adding: “These included a number of maternal and baby deaths and many cases where babies suffered brain damage.
“Families have told us of their experiences of pregnancies ending with stillbirth, newborn brain damage and the deaths of both babies and mothers. These families have shared with us their accounts of the overwhelming pain and sadness that never leaves them.”
An interim findings report said the hospital trust had caesarean section rates that were consistently 8-12 per cent below the average for England.
It said: “A typical quote during interviews was that ‘they didn’t like to do caesarean sections,’” adding: “Women who accessed the trust’s maternity service appeared to have little or no freedom to express a preference for caesarean section or exercise any choice on their mode of delivery.
“There was a culture within the Shrewsbury and Telford Hospital Trust to keep caesarean section rates low, because [that] was perceived as the essence of good maternity care in the unit. Overall there did not seem to be a consideration of whether this culture contributed to unnecessary harm.”
It said mothers had not been warned of the risks of giving birth in standalone midwifery led units far from hospitals, which in some cases led to catastrophic events including deaths.
“In many cases reviewed there appears to have been little or no discussion and limited evidence of joint decision-making and informed consent concerning place of birth.”
The inquiry warned the attitude and compassion of some midwives and doctors was poor.
“One of the most disappointing and deeply worrying themes that has emerged is the reported lack of kindness and compassion from some members of the maternity team at the trust. The fact that this has found to be lacking on many occasions is unacceptable and deeply concerning.
“There have been cases where women were blamed for their loss and this further compounded their grief.” Some concerns were “dismissed or not listened to at all” it said.
In one example from 2013 the report said a woman “was in great pain after delivering and left screaming for hours before it was identified that there were problems that needed intervention. The attitude of some midwives also made the situation worse.”
In another case a woman giving birth in 2011 was called “lazy” by an obstetrician and was made to feel “pathetic” by staff who dismissed her complaints that she was in agony. The report said this lack of compassion and kindness “has persisted” in the trust over a period of years.
It also found the “clinical care and decision-making of the midwives did not demonstrate the appropriate level of competence” including failures to recognise when there were problems with births.
Rhiannon Davies, whose daughter Kate died after a series of errors at the trust in 2009, lobbied for the inquiry. Reacting to Thursday’s findings, she told The Independent: “There can be no more complacency. There is a deep seated problem in maternity, a deeper seated problem in midwifery and a toxic issue at the heart of Shrewsbury’s specific midwifery and obstetric services.”
She said there was a culture of “normal birth at any cost” that had pervaded maternity services for decades and was part of midwifery ideology. “They need to accept when to escalate and not be arrogant. It’s not an admission of personal failure. It’s not letting your midwife colleagues down. You are not central to this. It’s about the mothers and their babies. And too many of them are coming to harm in your care.”
She said there were some staff at the Shrewsbury trust who had lied and blamed victims. “These people have caused death. They have caused catastrophic harm. They have caused untold suffering. They have no place in healthcare.”
Responding to the inquiry’s findings, Nadine Dorries, the minister for patient safety, said: “I expect the trust to act upon the recommendations immediately, and for the wider maternity service right across the country to consider important actions they can take to improve safety for mothers, babies and families.”
As part of a culture to promote “normal” or vaginal births, women were regularly given the drug oxytocin, which increases the strength and frequency of contractions, against guidelines and when mothers or babies were already struggling.
The report said there were “many examples where oxytocin was used injudiciously; these cases occurred across the time period of the 250 cases reviewed, which suggests a failure to learn from previous cases where the outcome was poor.”
In 2015 a woman whose baby was large was “persuaded to attempt a vaginal birth” despite requesting a caesarean section and having had an emergency caesarean section with an earlier child. The baby died a few days after birth and an investigation failed to acknowledge any poor care.
As early as 2000 women told the inquiry they felt their traumatic births were caused by the trust wanting to keep C-section rates low. In 2006 a woman whose baby was breech – or bottom first – was given oxytocin against guidelines. The baby died a few days later.
In some cases, the medication was used where babies were already demonstrating a dangerous heart rate and babies were delivered after long delays leaving them with brain injuries including cerebral palsy.
This culture and use of oxytocin also led to “excessive force” being used by doctors to deliver babies instrumentally using forceps, the report said.
It found there were “repeated attempts” of forceps delivery adding: “There was clear evidence that the operating obstetricians were not following established local or national guidelines for safe operative delivery.”
In 2007 a baby died after suffering “multiple skull fractures” following repeated attempts at forceps delivery and in 2012 a baby had a fractured humerus after a forceps delivery when the mother’s request for a caesarean section was refused. In a letter to the trust at the time, she said she felt the trust had wanted to keep its C-section rates low.
In another case during 2013 a baby died after two doctors repeatedly tried to deliver with forceps and then again in 2017 a baby suffered skull fractures and cerebral palsy after a forceps delivery. The report said there was no investigation into what happened.
The review said the cases showed attempts at vaginal deliveries that “should not have been attempted or should have been abandoned and the baby delivered by caesarean section. Some of these deliveries were undertaken by consultant obstetricians, which was particularly concerning.”
Failure to learn lessons
The report said midwives failed to raise the alarm when there were problems and when they did doctors did not act on them properly which it said indicated poor teamworking. Other problems include failures to properly monitor babies’ heart rates during labour, and not following up incidents with a full investigation.
The review found there were years of reports and recommended improvements which had not been implemented by the trust because of inconsistent processes.
“There is evidence that when cases were reviewed the process was sometimes cursory. In some serious incidents reports the findings and conclusions failed to identify the underlying failings in maternity care.
“The review team has also seen correspondence and documentation which often focused on blaming the mothers rather than considering objectively the systems, structures and processes underpinning maternity services at the trust.”
“We have found clear examples of failure to learn lessons.”
The report found a failure in leadership and a loss of what it called organisational memory by the trust which has had 10 chief executives since 2000 – eight since 2010 including four interims.
“As new CEOs started at the trust there was a tendency, until at least 2019, to regard problems at the trust as ‘historical’ or as a ‘legacy’ from previous years.”
The report also singled out inspections by the Care Quality Commission for varying “considerably” between 2015 when the trust’s maternity services were rated good, including for safety, and in 2018 and 2020 when the regulator was more negative and rated services inadequate.
The latter inspections were written only after widespread maternity concerns had already started to emerge.
The watchdog told The Independent it had also inspected the trust at the end of 2016 and rated the trust as requires improvement rather than good.
The Shropshire trust has been given 27 actions to improve safety including risk assessments for mothers at every antenatal appointment, better information and choices offered to women, improvements in baby monitoring and instructions that staff follow official guidance on care and use of oxytocin.
The trust has also been told to improve its investigation of incidents and that consultants must be involved in the care of all complex cases with twice-daily ward rounds on maternity units including night shifts.
A full report on the trust and considering all 1,862 cases will be published in 2021.