December 10, 2020

The Shrewsbury Maternity Scandal – the report’s findings and what all maternity services can learn from it

Earlier this morning Donna Ockenden, senior midwifery advisor to the Nursing and Midwifery Counsel wrote to Matt Hancock, publishing her interim report on what is widely talked about as the largest maternity scandal in NHS history.

The conclusions of this interim report are based on the experiences of 250 out of a total of 1862 families involved in the review. The report calls for urgent improvements to maternity care across the whole of the UK.

The Shrewsbury and Telford Hospital NHS Trust maternity care review

The investigation into Maternity Care at Shrewsbury and Telford Hospitals NHS Trust was launched in 2017, following what was thought to be a relatively small number of baby deaths at the Trust between September 2014 and May 2016. However, the investigation grew at an unprecedented rate and what started as a review into the care received by 23 families has now grown into a review of an astonishing 1862 families.

The investigation has been led by Donna Ockenden and looks into avoidable harm to mothers and babies under the care of the Trust between 2000 and 2019. The review looks in particular at maternal deaths, baby deaths and babies diagnosed with hypoxic ischemic encephalopathy, which is brain damage caused by a shortage of oxygen.

This report shares the findings of the review team to date, following review of the first 250 cases. The aim of this interim report is to bring to the nation’s attention the actions urgently required to improve both the safety of maternity services at Shrewsbury and maternity services nationwide.


This interim report highlights emerging themes from the 250 cases reviewed to date, including:

  • a lack of kindness: The report states that “One of the most disappointing and deeply worrying themes that has emerged is the reported lack of kindness and compassion from some members of the maternity team at the Trust…There have been cases where women were blamed for their loss and this further compounded their grief”.
  • a failure to choose the best place of birth: The report highlights that in many cases there appears to have been little or no discussion concerning the place of birth. This led to women with complex needs giving birth in stand alone birth centres without obstetric led care available.
  • a failure to escalate worrying signs of distress: The cases show repeated failures by midwives to raise concerns when mothers and babies were showing signs of distress; and failures by doctors to act upon those concerns when raised. This has resulted in delays in treatment with devastating consequences.
  • a lack of monitoring the unborn child: Fetal heart rate monitoring is integral to the safe management of labour. The review revealed significant problems with how fetal heart rate monitoring was interpreted and acted upon.
  • traumatic deliveries: The review team found evidence of repeated attempts at vaginal delivery with forceps, sometimes with excessive force and all with traumatic consequences. The report highlights the experience of one woman who was known to have a big baby and was refused her request for a caesarean section. She went on to have a forceps delivery which was complicated by shoulder dystocia.
  • inappropriate use of oxytocin: Oxytocin is commonly used to increase the strength of uterine contractions, however the review team noted many examples where oxytocin was used injudiciously resulting in fetal head impaction and other complications.

Immediate actions for the Trust

In response to these findings, the report provides immediate and essential actions required by the Trust as soon as possible:

  1. a thorough risk assessment must take place at the booking appointment and at every antenatal appointment to ensure that the plan of care remains appropriate and women should be fully informed to allow them to participate equally in all decision making processes;
  2. staff must follow the recognised guidance on fetal monitoring for the management of all pregnancies and births in all settings. Any deviations from this guidance must be documented, agreed within a multidisciplinary framework and made available for audit and monitoring;
  3. there must be a minimum of twice daily consultant-led ward rounds and night shift of each 24 hour period;
  4. complex cases in both the antenatal and postnatal wards need to be identified for consultant obstetric review on a daily basis;
  5. the use of oxytocin (a hormone used in induction of labour) must adhere to national guidelines and include appropriate and continued risk assessment in both first and second stage labour. Continuous CTG monitoring is mandatory if oxytocin infusion is used in labour and must continue throughout any additional procedure in labour.

Essential actions for all maternity care

Further actions are recommended for all hospitals providing maternity services within the UK, centred on:

  1. increasing partnerships across different hospital trusts;
  2. listening to women and their families;
  3. participating in regular training as a multidisciplinary team; and
  4. ensuring robust pathways are in place for complex pregnancies.

The review team plan to add to and strengthen these recommendations in their final report following completion of the review in 2021.

The future

The report calls for the themes of their report to be shared across all maternity services as a matter of urgency.

With the recommended changes implemented nationwide, the review team is confident that cases of harm to mothers and babies with be reduced, an outcome that we all hope for.

What to do if you believe you are affected

The lives of families impacted by this scandal may be affected forever. Below are details of a couple of charities that may be able to provide support and advice:

Stillbirth and Neonatal Death (Sands) Charity

Sands provides support to anyone affected by the death of a baby before, during or shortly after birth. They offer support groups, access to trained befrienders and have a wide range of bereavement support resources available online.

Peeps HIE Awareness and Support Charity

Peeps provides support to families affected by HIE. HIE stands for hypoxic-ischaemic encephalopathy where there is a lack of oxygen and blood flow to the brain. Peeps offer buddy support, where you can be paired up with a mum or dad who has been through a similar experience.


Your child may be affected by life changing disabilities as a result of substandard care either at this Trust or another hospital.

At Royds Withy King we walk alongside families in their journey of seeking compensation for their child and in ensuring funding to provide the care, support, and equipment their child may need for a lifetime. Do get in touch with us to find out more on how we may be able to help your family.

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