Lawyer for families: Improvements have been made to maternity care in Shropshire after baby deaths

An independent report by the Royal College of Physicians investigated the deaths at The Shrewsbury and Telford Hospital NHS Trust (SaTH) during 2021 and 2022.

At the time, senior midwife Donna Ockenden was reporting on SaTH’s failures that led to 200 deaths – at that stage, the biggest maternity scandal in NHS history.

The Royal College of Physicians’ review was commissioned by SaTH to understand the above average mortality noted in successive Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries (MBRACCE) reports.

It said that neonatal mortality at SaTH cannot be considered in isolation, and the West Midlands has the highest infant mortality rate in England. 

It added that no evidence was found that indicated that the quality of care provided to babies by the neonatal service was substandard or ‘directly contributed to the unit’s outlier status in terms of perinatal mortality’.

However, while five of the cases were graded as ‘good practice’, 10 were graded as ‘room for improvement’ and two ‘unsatisfactory’.

Laura Weir, a clinical negligence specialist with Lanyon Bowdler Solicitors in Shrewsbury, represents three of the families involved.

She said: “We support the need to investigate why the Shrewsbury and Telford Hospital NHS Trust, and the West Midlands as a whole, has the highest infant mortality in England.

“The Royal College of Physicians has been quite clear to state in the report that significant improvements have been made, which is reassuring to hear. It is encouraging that examples of excellent and good care have been identified, but the majority still experienced care that fell below the ‘good’ threshold.

“It is important to recognise the improvements and this will help to rebuild confidence in our community, but it is also important to remember there are 18 babies behind this report and the failures in their care must also be acknowledged. There is still work to be done to prevent further deaths.”

She added that the recommendations and timelines provided in the report were helpful and families were keen to see what further progress was being made.

“This report should be yet another blueprint for change and it will be interesting to see how the trust is progressing with the recommendations, which it received in December 2023 – almost a year ago – and it is not clear what has changed to date,” said Ms Weir.

“Whilst the trust will of course shine a light on the excellent care, you are only as good as your worst case and it is important to ensure that the focus remains on the failings so that real improvement and change can follow.”

Dr John Jones, executive medical director at SaTH, said: “Our neonatal teams care for unwell babies through the early critical days of their lives. We owe it to them and their families to give the best care.

“We wanted to understand how our services could be improved, and anything we could do to reduce the above-average perinatal mortality rates in the trust and across the West Midlands.

“The review team did not identify evidence to indicate that the quality of care provided to babies by the neonatal services was substandard or directly contributing to the unit’s outlier status in terms of perinatal mortality.

“However, although they described examples of good care, there were also examples of poor care that should have been significantly better. We apologise wholeheartedly for this.

“We have written to each of the 18 families whose baby or babies’ care was reviewed and have begun meeting with them, in person, to answer any questions and to offer support. We are grateful for their time and willingness to engage with us as we seek to improve our services wherever possible.”

The board of directors at SaTH were set to discuss the report at their meeting on Thursday (November 14).