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Will vital lessons be learned following Britain's worst maternity scandal?

View profile for Judith Thomas-Whittingham
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Midwife struck off for looking up confidential medical records

The Ockenden Inquiry into maternity services at the Shrewsbury and Telford Hospital NHS Trust reviewed almost 1,600 maternity incidents over a 20-year period and found that a staggering 201 babies could have survived had the Trust provided appropriate care. When the inquiry was first commissioned, it was intended to examine 23 cases, but this escalated to an incredibly concerning 1,592 cases, all associated with the same Trust.

In addition to this, there was avoidable harm caused to many other babies, some now left with significant lifelong conditions, such as cerebral palsy. Mothers were also subjected to unacceptable care and suffered harm and even worse, nine mothers died as a result of their failings.

How could this have gone unnoticed for 20 years? 

It didn’t. The Trust had been referred to the Healthcare Commission (HCC) and Clinical Commissioning Group (CCG) for investigation yet despite this, the investigators either failed to undertake the investigation or the investigation was inadequate allowing the Trust to continue its poor unacceptable practice and lead to more harm and death.

The inquiry worryingly revealed there was a culture of failing to listen to the families, in particular the mother’s concerns or wishes. Indeed, when tragedy struck, the Trust would even go so far as to blame mothers. 

Whilst the outcome of the inquiry has made a wide range of recommendations, the majority for that particular Trust, 15 for NHS maternity providers in general and a small amount for the government.

The inquiry has once again thrown a spotlight on significant failings and it is only now, many years on in some cases, that an active police investigation is underway.

Having supported families involved in maternity incidents for over the past 20 years, I am incredibly saddened to read the outcome of the inquiry and that in 2022, these tragedies are still prevalent. Lessons are not being learned and babies and mothers are paying the ultimate price. 

I commend the very brave 1,486 families who prompted the inquiry at the outset and the hundreds of families whose very painful experiences were shared during Donna Ockenden’s independent review.

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