Shropshire baby deaths: hundreds more cases under review

Last month the BBC reported that a further 300 cases would be added to an investigation regarding avoidable baby deaths at Shrewsbury and Telford Hospital NHS Trust (SaTH).

In January 2017, Jeremy Hunt, the then health secretary, ordered an investigation to examine avoidable baby deaths and injuries at SaTH. The BBC reported that, according to a local coroner, at least seven baby deaths were found to have been avoidable between September 2014 – May 2016. Evidence suggested that the majority of the avoidable deaths involved a failure to properly monitor fetal heart rates.

Following the inquiry, the number of families coming forward – whose babies were either stillborn or who had died after birth – began to escalate. The Department of Health said the investigation would examine “disclosures that in a number of tragic cases standards of care fell far below those that parents would expect”.

A separate analysis of all NHS trusts in England last year rated Shrewsbury and Telford as one of the worst in the country when it came to learning from mistakes and incidents, describing the trust as having a poor reporting culture.

In August 2018, an NHS Improvement spokesman said it had agreed “to consider additional historical investigations where women, infants and newborn babies had died or suffered harm in the maternity services provided by Shrewsbury and Telford Hospital NHS Trust”.

NHS Improvement (NHSI) has now asked for details of all cases involving neonatal deaths, stillbirths and babies with brain damage since 1998. Following this, a further 300 cases of concern came to light. However, not all these outcomes were because of sub-standard care. The independent investigation, being led by midwife Donna Ockenden, was already investigating 250 cases. Therefore, the total number of cases of mother and baby deaths and injuries under review now appears to exceed 500.

An NHSI spokesman said: “As part of the independent Ockenden Review, the trust was requested to share all potentially relevant information relating to maternity to establish if any more cases should be included in this investigation so that all families are given the answers they need and lessons are learned”.

Issues in maternity care are not limited to SaTH but the number of cases being investigated over the past decade at SaTH is incredibly high. There was clearly a problem at this trust, that allowed far too many errors to be committed, which devastatingly caused healthy babies to be harmed, or in the most tragic cases to die.

The fact that the investigation spans over a decade suggests that lessons had not been learnt previously. The shocking scale of those mistakes is only now being revealed. It is hoped that those families who have been affected will finally be given the answers that they deserve from the enquiry.

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