A major report into maternity failings at an NHS trust has found that at least 210 deaths could have been avoided.
At least 201 babies could have lived if their care had been better, including 131 who were stillborn and 70 who died soon after birth.
Nine mothers also died avoidable deaths.
In 94 cases, babies suffered avoidable long-term injuries, including brain damage, because of a lack of oxygen during their birth.
The report into more than two decades of avoidable harm to babies and mothers at the Shrewsbury and Telford NHS Trust has found that mothers were blamed for the deaths of their babies.
Some families were told mothers were responsible for their own deaths.
Richard Stanton, whose baby Kate died at the trust in 2009, told Sky News: “This has to be a watershed moment for maternity care across this country that a tragedy of this scale can never be allowed to happen again.
“Those who are in charge of policy need to make sure that policy is put in place and tested to make sure that this never happens again and also that bereaved parents are not at the forefront of having to uncover such tragedy.”
Julie Rowlings, whose daughter Olivia died 23 hours into labour after a consultant used forceps, said: “I would like somebody from the trust to sit face to face with me, and talk to me. They’ve never done that.
“They’ve apologised, via media, they’ve apologised to all the families via media, but they’ve never sat down with the families.”
The independent review, chaired by midwife Donna Ockenden, examined 1,592 clinical incidents involving 1,486 families. Most of the incidents occurred between 2000 and 2019.
Repeated failure to learn from mistakes
The report found a culture that favoured natural birth led to a reluctance to perform caesarean sections which resulted in many babies dying.
There was a failure to properly assess the risk to patients, a failure to properly monitor babies and a repeated failure to learn from mistakes.
Ms Ockenden said: “Throughout our final report we have highlighted how failures in care were repeated from one incident to the next.
“In many cases, mothers and babies were left with lifelong conditions as a result of their care and treatment.”
“The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved.
“There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths.
“What is astounding is that for more than two decades these issues have not been challenged internally and the trust was not held to account by external bodies.
“Systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding.
“Going forward, there can be no excuses.”
‘Harrowing picture’ of repeated failures in care
Her report identifies more than 60 areas in which the Shrewsbury and Telford Trust must take action.
The review has also outlined 15 areas in which all maternity services in England must take action to improve patient safety.
Louise Barnett, the trust’s chief executive, who was appointed in 2020, said that today “belongs to the families who have been failed by our trust”.
Acknowledging that “nothing can take away from the pain and distress caused”, she said that “as chief executive now, I want to apologise fully for the failures”.
The trust had, she said, “delivered against all of the actions that are within our control” included in Ms Ockenden’s first report in 2020.
Ms Barnett promised they “will focus on this report with the same determination, commitment and resolve to improve our care”.
Responding to the findings, Health Secretary Sajid Javid said: “Donna Ockenden’s report paints a tragic and harrowing picture of repeated failures in care over two decades, and I am deeply sorry to all the families who have suffered so greatly.
“Since the initial report was published in 2020 we have taken steps to invest in maternity services and grow the workforce, and we will make the changes that are needed so that no families have to go through this pain again.”
Mr Javid also issued an apology in the Commons on Wednesday afternoon for the maternity service failings reported at the trust.
“We entrust the NHS with our care, often when we’re at our most vulnerable. In return we expect the highest standards,” he told MPs.
“I have seen with my own family the brilliant care the NHS maternity services can offer. But when those standards are not met, we must act firmly and the failures of care and compassion that are set out in this report have absolutely no place in the NHS.
“To all the families that have suffered so gravely, I am sorry.
“The report clearly shows that you were failed by a service that was there to help you and your loved ones to bring life into this world.
“We will make the changes that the report says are needed at both a local and national level.”
Jeremy Hunt, chair of the Commons health and social care committee, said: “Today’s report goes beyond my darkest fears when I commissioned it as health secretary.”
Jacqueline Dunkley-Bent, England’s chief midwifery officer and Matthew Jolly, national clinical director for maternity and women’s health, also apologised, saying in a joint statement: “Our thoughts are with all those who have been put through this devastation and we are sorry for the loss and the pain they have experienced.”
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