May 4, 2020

The Shrewsbury and Telford Maternity Review – a final appeal to families

The Shrewsbury and Telford NHS Trust Independent Maternity Review was commissioned in 2017 following a small cluster of baby deaths. In November 2019, a leaked interim report prepared as part of the inquiry revealed that more than 600 cases were being examined. On 21 April 2020, it was revealed that nearly 1200 cases are being investigated. A final appeal has now been made to families to make contact by the end of May 2020.

Why was the investigation launched?

The investigation into Maternity Care at Shrewsbury and Telford NHS Trust was launched in 2017.  The inquiry was initially set up following a cluster of deaths at the Trust between September 2014 and May 2016. These included the tragic deaths of Ella and Lola Green, twins who were stillborn after a failure to read and act on their heart rates; Oliver Smale who died in 2015 and whose untimely death is likely to have been avoided if he had been born promptly by caesarean section; and Pippa Griffiths who passed away at just 1 day old following a delay in diagnosing that she had an infection.

The purpose of the investigation was to look into avoidable harm to mothers and babies under the care of the Trust, looking in particular at maternal deaths, still births, neonatal deaths and babies diagnosed with hypoxic ischemic encephalopathy, which is brain damage caused by a shortage of oxygen.

The investigation is being led by Donna Ockenden, senior midwifery advisor to the Nursing and Midwifery Council.

What will the investigation tell us?

Although the final report of the investigation is not due to be published until next year, The Independent obtained a leaked interim report from the inquiry in November 2019.

My colleague, Sarah White, published a blog highlighting what the leaked report told us about the care that mothers and babies had received. The report revealed that dozens of babies had died unnecessarily.

How did this become such a wide-scale review?

When the review started, the scale of the enquiry could never have been anticipated. At the outset, the scope of the inquiry was initially to look into the care of 23 families who had suffered from avoidable harm under the care of the maternity units at the Trust.

On 21 April 2020, however, it was confirmed that the number of families involved in the maternity review now stands at 1170. The same press release confirms that 400 families were written to last week to explain that their cases had been identified and to ask those families if they would like to be included in the review.

Donna Ockenden states:

“By writing to all these families I am giving them the opportunity to ask questions about our independent review so they can make a choice as to whether they want their care to be independently reviewed by my team. We appreciate that any contact can be unsettling for families, but it is vital that our independent review reaches out to all potentially affected families.”

What is the response of the Shrewsbury and Telford NHS Trust?

I can only imagine that this recent press release is not only devastating for the families affected but also for the Trust’s doctors and midwives, as the scale of what has taken place over the last 40 years is revealed.

Paula Clark, Interim Chief Executive at The Shrewsbury and Telford Hospital NHS Trust, said:

“We have been working, and continue to work, with the independent review into our Maternity services. 

On behalf of the Trust, I apologise unreservedly to the families who have been affected. I would like to reassure all families using our Maternity services that we have not been waiting for Donna Ockenden’s final report before working to improve our services. A lot has already been done to address the issues raised by previous cases.”

What to do if you believe you are affected

Although the final report is due to be published next year, Ms Ockenden’s enquiry team has set a deadline of the end of May 2020 for any additional families to get in touch.

Donna Ockenden states:

“I want to assure people that despite this covid crisis progress is continuing and today I am making one last appeal to any family yet to get in touch to please do so by May 2020. I have made a commitment to the Secretary of State for Health and Social Care to deliver my final review report. We have to give ourselves the time to write the report and ensure it does justice to the testimony we have heard from families. So please get in touch by the end of May. Your story is important to us.”

To get in touch with the independent maternity review team please email Donna on:
[email protected]

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