A report on one of the most scandalous episodes in the history the NHS will be published next month. It concerns the failures to provide maternity care at the Shrewsbury Hospital NHS Trust and Telford Hospital NHS Trust. Michael Buchanan, a BBC journalist who helped to uncover the problems, examines how so many failures were allowed.
It all began with an email exchange between mothers. They were completely strangers. The two of them were strangers. But a bond was formed almost immediately – a spark that rekindled a love between a couple who had just two months ago promised to move on in their lives.
Kayleigh Griffiths wrote the email on Monday, June 16, 2016, in a moment when she was clear in the fog of grief. Colin, her husband, had just welcomed Pippa their second child into the world in April.
Because of the “appalling” state of Shrewsbury’s birthing center, they decided to have a homebirth. Pippa arrived safe, but she struggled to eat almost immediately. Kayleigh spoke with her midwifery team four times about her concerns. Kayleigh also called her frantic number at 03:00 to report that her daughter had coughed up brown liquid. She was told repeatedly not to worry.
Pippa stopped responding to commands by 11:30 am the next morning. Kayleigh recalls, “I stayed still and observed her chest. It wasn’t moving.” “I placed my hand on her nose to feel her breath, and it was still there. Then panic broke out. She began screaming for Colin, who tried desperately to revive her daughter while an ambulance was dispatched.
Pippa was killed that afternoon. She was only 31 years old. They were later informed that the cause of her death was Group B Strep. The Shrewsbury and Telford NHS Trust informed the family that they would conduct an investigation. Kayleigh called the trust after several weeks of silence to learn that it was an internal investigation, and that the couple wouldn’t need their input. Kayleigh, a NHS auditor from a different trust, was concerned that the truth might be hidden. She decided to send the email.
Rhiannon Davies was in Pembrokeshire on holiday with Richard Stanton at the time she received the message. Kayleigh had seen the extensive local media coverage on the couple’s seven year effort to discover the truth about their daughter’s tragic death in the same Shropshire trust.
The joy of a new life was quickly overshadowed by the shock of the sudden loss. Rhiannon was pregnant with their first child in 2008, and had been a mother to them since then. After being assessed as a low-risk pregnant, Rhiannon was advised to have her baby at a Shropshire trust-run birthing center in Ludlow.
She noticed a decrease in the baby’s movements during the days leading to her birth. She reported her concerns at the trust to clinicians, who said that she had a lazy child. Rhiannon gave birth to Rhiannon on March 1, 2009. She was referred to the midwife-led unit. Richard recalls that Kate was born at 10:03 AM. It’s hard to express the joy you feel.
Rhiannon claims that Kate began to make strange sounds. It’s known as grunting, but it’s actually a murmuring sound. She was crying, the midwife stated. The baby was not crying, but the midwife said she wasn’t. This is a clear indication, if you know what to do, that the baby has respiratory distress. Beautiful blue eyes opened once she looked up.
Kate was very ill and required urgent medical attention. The nearest doctor was 45 minutes away. Richard said that the midwives had “lost control” of the situation, but an air ambulance was able to transport Kate to a Birmingham hospital. Following the couple, Rhiannon fell and was taken to Worcester Hospital.
Richard raced to his little girl’s side. He recalls that Kate was in an incubator cot with tubes and cables. This was the worst situation I have ever seen. Six hours later, holding my newborn baby, I held Kate in my arms and died. That one day, the most vivid memory is Rhiannon calling to tell us that Kate had passed away. Rhiannon’s cries of pain are also what I remember.
Initial reports from the trust mentioned the death, but described it as an “no harm” event. An inquest jury found that Kate’s death could have been prevented in 2012. Rhiannon should have delivered in a hospital with doctors present. The trust responded in writing that the care given to Ms Davies was consistent with national and local guidance.
The couple continued their fight and demanded two independent reports. These were published in the following four years. In April 2016, the trust board held an extraordinary meeting in which they apologized and admitted that Kate’s death could have been avoided. Rhiannon says that it was an extremely emotional experience, but that it was one that was very,very, very difficult for them.
Rhiannon could have easily ignored June’s email, but Kayleigh said that there was something special about Rhiannon and she needed to respond. The two of them are in many ways polar opposites. Kayleigh is calm and analytical while Rhiannon is energetic and passionate. The Griffiths family required practical advice about how to hold the trust accountable. Richard and Rhiannon offered that advice, and in April 2017, a coroner ruled Pippa’s untimely death preventable because the trust failed to provide the family with information that would have allowed them recognize the severity of her condition.
Their conversations became more complicated as the mother-child bond grew stronger. They began to suspect that the Shropshire trust had provided poor maternity care and they searched the internet, coroner records, and death notices.
They compiled 23 cases that date back to 2000, including stillbirths and neonatal deaths as well as babies with brain injuries. They were shocked by the findings and wrote to Jeremy Hunt, then health secretary, in December 2016 asking for an investigation. The review was led by Donna Ockenden, a senior midwife.
Panorama was told by Ms Ockenden that she and her colleagues looked through the original 23 cases notes. “We were convinced these are very serious cases,” Ms Ockenden said. These are some of the most difficult cases we have ever seen in our professional careers. It is likely that if one tried to piece together the whole puzzle, there would be more cases. But we didn’t know this at the beginning.
I knew there were serious problems with the trust by now. In late 2016, Richard and Rhiannon had met me and I began investigating. In April 2017, I discovered that there had been seven deaths at the trust within the span of just 20 months. I was inspired by that initial story to embark on a five year investigation, which has led me to unravel years of grief and failure.
As I discovered more failures, the number families who approached Donna Ockenden grew rapidly. Initially, it was an investigation into 23 cases. But the review team now examines the care received by 1862 families.
Panorama
Maternity Scandal – Fighting for the Truth will be on BBC One Wednesday 23 February at 21:00, or later on BBC iPlayer
In a December 2020 interim report, the inquiry noted that trusts often failed to investigate when something went wrong or just carried out their own investigation. Panorama discovered that the trust had its own investigation system called a High Risk Case Review.
It was not part of any national framework used to learn from incidents. The unorthodox system also meant that less incidents were reported to the NHS regulators. This limited the opportunities to learn from them.
Kathryn Leigh’s 2000 death was one of the first cases to be added to the original 23 that the couples had compiled. Panorama investigated the case and found that the same theme was repeated in subsequent incidents.
Kathryn was born in poor condition after an emergency caesarean. Her mother had been in labor all night. The baby died 21 minutes after her birth. The trust acknowledged the error, but refused to admit fault in its maternity care during Kathryn’s April 2003 inquest.
The court heard from an expert witness, Kathryn Leigh, who was called by the coroner to testify that Kathryn Leigh needed resuscitation because of incompetent management during her mother’s pregnancy.
Panorama can confirm that the family’s lawyer raised this concern in court. He asked whether there was an “inbuilt policy” or bias to try to have natural births in as many cases possible. Kathryn’s parents Phil and Sonia also inquired into the matter. Sonia said, “I was curious about why I had been so far away from C-section.” “I did extensive research and discovered that Shrewsbury Hospital had one of the lowest rates of C-sections across the UK.
The majority of cases that Ockenden is reviewing date back to 2000-2019. Their interim report highlighted the core of Sonia Leigh’s concerns. Inquiry found that Shropshire’s rates of caesarean section were as high as 12% lower than the England-average for the time period under review.
It was well-known that the trust had a reputation for having unusually high rates of vaginal births. Panorama discovered that a parliamentary hearing was held just one month prior to Kathryn Leigh’s inquest to address concerns over the increasing number of caesarean deliveries across England.
Concern was raised about childbirth being over-medicalized and too many women having to have unnecessary surgery. This, like all operations, carries risks. It is also more expensive.
The Royal Shrewsbury was however, praised for its unique approach. The hospital’s caesarean rates were only half of the England average at the time. A team from the hospital traveled to London.
Panorama filmed Panorama’s evidence session. Then-clinical director of Royal Shrewsbury, Dr. James Shrewsbury, stated that the Royal Shrewsbury had low intervention rates. Once that was known, midwives as well as obstetricians will be attracted to the hospital.
His manager at the time of women’s services, his colleague, said that midwives from other countries “almost need to retrain to be able work in Shropshire.” We’ve found people with similar values. You don’t want to hire people who don’t believe in the same things you believe.
Donna Ockenden shared her initial findings with Panorama. She stated that there were instances where a mother could have had a caesarean instead of a persistent desire for a normal delivery. A prize was the low rate of caesarean sections. They were praised by the trust.
While the Stanton–Davies and Griffith families tried to bring a rigorous external inspection to the Shrewsbury trust and Telford trust, Bernie Bentick inside the organization was also pushing for change. He was a consultant obstetrician/gynaecologist at the Shrewsbury & Telford trust for almost 30 years, retiring in 2020. He is the first ex-staff member to openly discuss what was going on inside.
Panorama was told by him that he had written to senior management several times highlighting problems.
“I was supported and encouraged by many of my clinical colleagues. I wrote a long email describing the severity of problems to my line managers, to chief executive. It included incidents of dysfunctional culture, bullying, and the imposition of changes to clinical practice that many clinicians considered unsafe.
He said that although there was an “ingenious attempt to ensure the highest standards were achieved” in the maternity department’s maternity section, staff became more anxious and cautious which made their performance less than ideal.
Dr Bentick stated that “because resources were limited”, there was a tendency for people to blame others for not following the guidelines. Instead of looking at the root causes, such as staffing levels in midwifery departments, or the specific problem. Often, there wasn’t enough.
Panorama spoke to former employees who claim that the trust had struggled for years with a shortage of consultants and midwives. According to the Royal College of Obstetricians and Gynaecologists, there is a shortage of staff on maternity wards in the country. They believe that thousands more midwives are needed and hundreds of more obstetricians will be needed. They say that additional funding is needed for maternity services of up to PS300m per year.
Bernie Bentick responded to his complaints by saying that he had launched some “cursory investigations” but that management had not got to the root of the problem. “I believe that they tried to preserve the organisation’s reputation rather than do anything practical.
“They were willing to make small changes that they considered proportionate to improve the situation. However, I doubt they understood the seriousness of the cultural issues within the trust.
He said that a gap has developed between the trust’s management and its clinicians in recent years. This was due to a problem facing the entire NHS: the shortage of qualified managers with as much professional accountability for clinicians as the good quality of their staff.
“If there had been sufficient resources to hire enough people, the situation might have been very different.” I am deeply sorry for the families. I hope the NHS responds to ensure that quality care is provided in the NHS.
Ockenden’s team has spoken with more than 800 families. It was once more than 80 clinicians. The trust failed repeatedly in nine areas, according to the interim report. They also highlighted low caesarean rates and the misuse of labour-inducing drugs, excessive forceps use, failure to escalate concerns to senior clinicians, and lack of compassion and kindness when delivering care.
Donna Ockenden said, “I have heard of mothers being told very clearly that it was their fault.” “And I’ve heard from fathers who carried so much guilt they were unable to stand up for their partners and wives. It is not your guilt to bear, I tell them.
Ockenden’s team noticed a common theme in staff failure to monitor baby’s heart rate. This problem raises serious questions for all NHS bodies responsible for overseeing trusts, as it was raised at the Shropshire trust in 2007.
The failure was cited as a contributing factor to two cases of severe brain damage in babies born to prematurely. In 2004 and 2005, Healthcare Commission, at that time the regulator, wrote to the trust requesting action to ensure the problems were not repeated and that learning is occurring. There is no evidence that the regulator followed-up, with multiple catastrophic consequences.
The Care Quality Commission (CQC), the new regulator, didn’t notice the error. The CQC’s October 2014 and December 2016 inspections of the trust didn’t find any mention of a problem monitoring baby’s heart rate. The CQC did not recognize the need to train baby’s heart rate monitors until November 2018.
Professor Ted Baker, Chief Inspector of Hospitals at CQC, defended the organisation’s handling on the trust. Panorama was told by him that the families of Shrewsbury, Telford were crucial in driving the improvements forward. “The regulators found problems in the maternity services and took enforcement action. “I don’t believe that we didn’t see the problem.
The trust stated that they accept full responsibility for the failures in maternity care. “We sincerely apologize for the pain and distress we have caused.
“Apologies are not enough. They must be backed up by clear, meaningful action. We have made significant progress, with substantial investment in staff training and additional staff. We have implemented more than 80% the recommendations from the interim Ockenden report.”
They stated that the term High Risk Case Review was “no longer being used” and that it is “aligning its investigation systems with those that are “being developed across NHS England.”
The scale of the maternity mistakes in Shropshire may mean that the well of grief is deeper, but it’s not just one area where women and babies have been hurt. Independent investigations were ordered in recent years into the maternity services of South Wales, East Kent and Cumbria.
The CQC has been assessing the safety of England’s maternity services since 2017. The latest CQC figures show that 41% need to improve their safety while only 1% are considered outstanding. CQC states that the rate of improvement isn’t good enough. Jo Mountfield, vice-president of the RCOG, believes it’s likely because many of the patients are women. “I believe women’s health and research should be given a higher priority in this country.” “I believe women’s voices should be heard louder.”
The Ockenden interim report resulted in an investment of almost PS100m in England’s maternity services. NHS England wrote last week to all health trusts, urging them not to limit the number and types of caesareans they offer women. They stated that they are committed to providing safe and compassionate maternity services.
Next month’s publication of Donna Ockenden’s final report will mark a turning point in the history and evolution of the NHS. It will reveal multiple cases of maternity failures in rural England. Pippa Griffiths was less than 40 hours away from Kate Stanton Davis, but their legacy in terms of better maternity care could last for decades.
Phil Coomes photographs
