• Leaked update report identifies 42 baby deaths spanning 40 years 
  • Highlights “toxic” culture and lack of kindness to families
  • Investigation examining details of hundreds of cases
  • Police discussing potential prosecution

A leaked report on maternity failings at Shrewsbury and Telford Hospital Trust outlines extensive care failings linked to the deaths of 42 babies and three mothers, over a period of 40 years.

The independent investigation – commissioned in 2016 – has identified more than 600 cases of potential poor care, according to the interim update on its work, which has been revealed by the Independent.

In addition to the 45 deaths, these include 51 children who suffered permanent brain damage and a further 47 cases of other potentially substandard care.

Reviews into all the 600-plus cases have not been completed, so further failures could still be highlighted.

Jeremy Hunt, then health secretary, commissioned senior midwife Donna Ockenden to carry out an independent investigation into 23 allegedly avoidable neonatal and maternal deaths at the Shrewsbury and Telford trust. HSJ revealed last year that the review was widened to include dozens of cases, and subsequently this has expanded to more than 600 cases of potential poor care.

The scale of the problems, harm and duration of the issues indicated in the interim update are greater than those uncovered in the well known Morecambe Bay maternity care scandal.

The problems contrast with the Care Quality Commission rating the trust’s maternity services as “good” in 2015 and 2017. Looking back to the last decade, however, in 2007 the CQC’s predecessor, the Healthcare Commission, wrote a letter to the former chief executive of the trust raising a number of concerns about its maternity services.

According to the interim Ockenden report, local commissioners Shropshire and Telford and Wrekin clinical commissioning groups carried out a review in 2017.

The interim report raised questions over reviews carried out by the Royal College of Obstetricians and Gynaecologists, one of which it said was based on some “flimsy evidence”.

Other failures in the maternity services highlighted in the update document, reported by the Independent, include:

  • A culture at the trust which is “toxic” to improvement;
  • A lack of informed consent for mothers;
  • A long-term lack of transparency, honesty and a lack of communication with families using maternity services at trust when things go wrong;
  • Failure to correctly categorise serious incidents;
  • Long-term failure to involve families in serious incident investigations;
  • A “distinct” lack of kindness and respect to parents and families;
  • A lack of maternity bereavement support for families; and
  • A failure to learn from serious incident investigations.

The newspaper has already reported that West Mercia Police are considering criminal charges against the trust in relation to the failings, including corporate manslaughter.

In a statement on Tuesday, the trust said it had not seen or received a copy of the report, despite Ms Ockenden having described it as a “status update for the consideration of NHS Improvement and the trust”.

The trust said it had already been making improvements in relation to concerns about the maternity services, however, and apologised to families affected by the care failures.

In relation to its ratings of the service and trust, a CQC spokeswoman said: “The 2014 inspection of all core services, including maternity, resulted in an overall trust rating of requires improvement.

“The inspection in December 2016 rated the trust’s maternity services as good overall, but at the Princess Royal Hospital, maternity services were rated as requires improvement for safety due to concerns about the processes in place to ensure staff in the maternity department were consistently reporting incidents and using learning from incidents to help drive improvement.

“In 2018 CQC took enforcement action against the trust to ensure the safety of patients using its maternity and emergency services, and the trust was placed into special measures. We continue to monitor the trust closely and the report of our most recent inspection will be published in due course.”

Bill Kirkup – who chaired the inquiry into the Morecambe Bay scandal – told HSJ, when asked about the case, that trusts “conceal their problems” from the CQC.

Dr Kirkup said: “When major problems arise, it seems that the first resort of many organisations is not to be open but to conceal their problems in the hope that they can resolve them without having to disclose them.

“This is done under the guise of ‘reputation management’. When those circumstances arise, it makes the task of any regulator difficult.”

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