Next month, a report will be published into one of the biggest scandals in the history of the NHS, the failures of maternity care at the Shrewsbury and Telford Hospital NHS Trust. The BBC’s Michael Buchanan who helped uncover the problems examines why so many failures were allowed to happen for so long.
It began with an email from one mother to another. The two were strangers – “I hope you don’t mind me contacting you and I hope I don’t cause any upset.” But almost immediately, a bond was formed – a spark rekindled in a couple who just two months earlier had vowed to move on with their lives.
It was a Monday evening in June 2016, when Kayleigh Griffiths in a moment of clarity amid the fog of grief, wrote the email. She and her husband Colin had welcomed their second daughter Pippa into the world in late April.
They had decided on a home birth because of what she said was the “appalling state” of the birthing centre in Shrewsbury. Pippa arrived safely but struggled to feed almost immediately. Kayleigh spoke to her midwifery team on four occasions about her concerns, including a frantic call around 03:00 after her daughter coughed up brown liquid. She was repeatedly told not to worry.
By 11:30 the following morning, Pippa became unresponsive. “I went still and watched her chest and it wasn’t moving,” recalls Kayleigh. “I put my hand under her nose to feel the breath and there was nothing. At which point utter panic set in.” She screamed for Colin who desperately started trying to resuscitate his daughter while an ambulance was called.
Pippa died that afternoon. She was just 31 hours old. The cause of death, the couple were later told, was an infection – Group B Strep. The Shrewsbury and Telford Hospital NHS Trust told the family they would carry out an investigation. But after several weeks of silence, Kayleigh contacted the trust to be told it was an internal investigation and the couple’s input wouldn’t be required. Kayleigh, an NHS auditor at a different trust, feared the truth was being hidden from her. That’s when she decided to send the email.
Rhiannon Davies was on holiday in Pembrokeshire with her husband Richard Stanton when she received the message. Kayleigh had seen some of the significant local media coverage about the couple’s seven-year effort to uncover the truth about their daughter’s death under the care of the same Shropshire trust.
Over a frenetic few hours the sheer elation of new life became overwhelmed by the grief of sudden loss. Rhiannon had become pregnant with the couple’s first child in 2008. She had been assessed as being a low-risk pregnancy and was advised to have her child at a midwife-led birthing centre run by the Shropshire trust in Ludlow, her home town.
In the days leading up to the birth, she noticed her baby’s movements had reduced. She reported her concerns to clinicians at the trust, but was told she simply had a lazy baby. So when Rhiannon went into labour on 1 March 2009, she headed to the midwife-led unit. “Kate was delivered at 10:03 in the morning,” recalls Richard. “It’s just hard to describe the happiness that you feel.”
Rhiannon says Kate started to make a strange noise. “It’s called grunting but it’s not, it’s a murmuring. The midwife said she was trying to cry. She wasn’t – this is a distinct clear sign, if you know what you’re doing, that the baby is in respiratory distress. She opened her eyes once, beautiful blue eyes.”
Image source, Family handout
Kate was seriously ill and needed urgent medical attention. But the nearest doctors were 45 minutes away. The midwives “lost control of the situation,” said Richard, but eventually an air ambulance arrived to take Kate to a hospital in Birmingham. The couple followed, but Rhiannon collapsed and was taken to hospital in Worcester.
Richard raced to his daughter’s side. “Kate was in an incubation cot with cables and tubes,” he recalls. “There was no recovery from this situation. So six hours after holding my new born baby, I cradled Kate in my arms dying. The overriding memory I have from that one day is hearing Rhiannon arrive to be told that Kate was no longer with us, and the cries of pain from Rhiannon.”
The initial report from the trust noted the death but described it as a “no harm” event. In 2012, an inquest jury concluded, however, that Kate’s death was preventable – those reduced movements should have seen Rhiannon deliver in a hospital, with doctors on hand. In a written response however, the trust said the care “given to Ms Davies was in line with both the local and national guidance”.
But the couple continued to fight, pushing for two independent reports, which were published over the next four years. Finally, in April 2016, the board of the trust held an extraordinary meeting, in which they apologised and accepted Kate’s death was avoidable. “It was a very emotional experience,” says Rhiannon, “but it was one that was very, very, very much for us the end.”
Rhiannon could easily have ignored the email in June, but there was something about Kayleigh, she says, that meant she had to respond. In many ways, the two are polar opposites – Kayleigh is quiet and analytical, Rhiannon energetic and passionate. The Griffiths family needed practical advice on how to hold the trust to account. Richard and Rhiannon provided that, and in April 2017 a coroner ruled that Pippa’s death was preventable as the trust had failed to give the family information that would have allowed them to recognise the seriousness of the infant’s deteriorating condition.
As the bond between the mothers deepened, their conversations morphed into something else. Armed with little more than a gnawing suspicion, they started to scour the internet, coroner’s records and death notices to see if any other families had received poor maternity care at the Shropshire trust.
These are amongst the most serious cases that we have seen in our careers
They collated 23 cases dating back to 2000 – including stillbirths, neonatal deaths, maternal deaths and babies born with brain injuries. Appalled by what they had found, they wrote to the then health secretary Jeremy Hunt in December 2016, asking him to order an investigation. He agreed and in May 2017, senior midwife Donna Ockenden was appointed to lead the review.
“We sat looking through the case notes of the original 23, and our opinion was these are really, really serious cases,” Ms Ockenden told Panorama. “These are amongst the most serious cases that we have seen in our careers. The likelihood would be that when one tried to put together the full jigsaw there would be other cases but we didn’t know that at the outset.”
By now I was aware of significant problems at the trust. I’d met Richard and Rhiannon in late 2016, and when they outlined their concerns, I started investigating. In April 2017, I revealed there had been at least seven avoidable deaths at the trust in just 20 months. That initial story set me off on a five-year quest, an investigation that has helped unravel years of failure and grief.
As I revealed more failures, the number of families approaching Donna Ockenden escalated rapidly. It was initially an investigation into 23 cases – but the review team has now examined the care that 1862 families received.
One of the themes the inquiry has already noted, in an interim report published in December 2020, is that in many cases the trust failed to investigate after something went wrong, or simply carried out its own inquiry. Panorama has discovered the trust even developed its own investigation system, what they called a High Risk Case Review.
It was outside any national framework that has been used to help learn lessons from incidents and doesn’t appear to be a system that’s used in any other NHS organisation. Another consequence of the unorthodox system was that fewer incidents were reported to NHS regulators, limiting the opportunity to learn lessons.
One of the earliest cases on the original list of 23 compiled by the two couples was the death of Kathryn Leigh in 2000. Panorama has investigated the case and discovered that a theme identified almost two decades ago was to come up repeatedly in subsequent incidents.
Kathryn was delivered in a poor condition following an emergency caesarean section after her mother had been in labour all night. She needed to be resuscitated but the medics used the wrong equipment, and the baby died within 21 minutes of her birth. The trust admitted that error but refused to accept criticism of its maternity care at the inquest into Kathryn’s death, held in April 2003.
An expert witness called by the coroner told the court, “In my opinion, Kathryn Leigh’s need for resuscitation arose from incompetent management of her mother’s pregnancy and labour”.
That criticism, Panorama can reveal, did lead the family’s lawyer to raise in court whether there was “any kind of inbuilt policy or inbuilt bias towards trying to achieve natural births in as many cases as possible”. The question also built on inquiries made by Kathryn’s parents, Phil and Sonia. “I wondered about the fact that I’d been left so long before going to C-section,” said Sonia. “I did a lot of research and found out that Shrewsbury Hospital had the lowest rate of C-sections in the whole of the UK.”
Most of the cases the Ockenden review is examining date from 2000-2019. In their interim report, the essence of Sonia Leigh’s concerns was strongly highlighted. The inquiry found that rates of caesarean sections at the trust in Shropshire were up to 12% lower than the England average for the period they are examining.
The trust’s reputation for unusually high numbers of vaginal births was known. Panorama has discovered that just a month before Kathryn Leigh’s inquest, a parliamentary hearing was held to discuss concerns about the rising number of caesarean births across England.
There was concern that child birth was being over-medicalised, and that too many women were having to undergo unnecessary surgical procedures, which like any operation carries risk. It also costs more money.
One hospital was praised for its approach however – the Royal Shrewsbury. At the time, its caesarean levels were half the England average, and a team from the hospital travelled to London.
In the evidence session, seen by Panorama, the then clinical director of the Royal Shrewsbury told MPs: “The culture of our organisation is that we have low intervention rates and once that is known we attract both midwives and obstetricians who like to practise in that way.”
His colleague, the manager of women’s service at the time, added that midwives who had worked elsewhere “almost need retraining to be able to work in Shropshire. We have recruited people who are like minded. If you want to keep something going and you believe in it, you do not want to employ people who do not believe in what you believe in.”
Discussing the initial findings of her inquiry, Donna Ockenden told Panorama, “There were cases where an earlier recourse to caesarean section rather than a persistence towards a normal delivery may well have led to a better outcome for mother or baby or both. Low caesarean section rates were a prize.” And the trust had been lauded for them.
As the Griffiths and the Stanton-Davies families were striving to bring rigorous external scrutiny to the Shrewsbury and Telford trust, inside the organisation Bernie Bentick was also agitating for change. A consultant obstetrician and gynaecologist for nearly 30 years at the Shrewsbury and Telford trust until he retired in 2020, he’s the first former staff member to speak openly about what was happening on the inside.
I believed that some of the ways they responded to problems were to try to preserve the reputation of the organisation rather than to do anything practical
He told Panorama that he wrote to senior management on several occasions highlighting problems.
“I was supported by a number of my clinical colleagues and wrote a long email to my line managers, to the chief executive, outlining the severity of the problems as I saw it – incidents of dysfunctional culture, of bullying, of the imposition of changes in clinical practice that many clinicians felt was unsafe.”
He says that while there was a “genuine attempt to try to ensure the best standards were achieved” within the maternity department, the deteriorating culture made staff increasingly “anxious” and “cautious”, making their performance “less than ideal”.
“Because resources were scarce,” said Dr Bentick, “there was a tendency to blame individuals for not following guidelines rather than look at the underlying factors which may have led to a particular problem, and in particular staffing levels in the midwifery department. There were frequently not enough.”
A lack of both midwives and consultants was a problem for years at the trust according to former employees that Panorama has spoken to. But there are too few staff in maternity wards across the country, according to the Royal College of Obstetricians and Gynaecologists (RCOG). They say thousands more midwives and hundreds more obstetricians are needed now. Maternity services, they say, need additional funding of up to £300m a year.
In response to his complaints, Bernie Bentick said some “cursory” investigations were launched, but he felt that management never got to the heart of the problems. “I believed that some of the ways they responded to problems were to try to preserve the reputation of the organisation rather than to do anything practical.
“They were prepared to make small, what they regarded as proportionate, changes to try to improve the situation. But I don’t think they really understood the gravity of the cultural problems within the trust.”
In recent years, he said, a gap developed between the management of the trust and its clinicians, which he says was mainly caused by a problem the whole NHS faces – the lack of good quality, trained managers who have as much professional accountability as clinicians.
“If the resources had been made available to employ adequate numbers, then the situation may have been profoundly different. I feel intense sorry and sadness for the families and I would hope that the NHS responds in a way that ensures that quality of care is at the forefront of what we provide in the NHS.”
The Ockenden team, which at one point grew to more than 80 clinicians, has now spoken to more than 800 families. Their interim report found nine areas where the trust had repeatedly failed. As well as low caesarean rates, they highlighted the excessive use of forceps, the repeated misuse of a labour inducing drug, a failure to escalate concerns to senior clinicians and a lack of compassion and kindness in the delivery of care.
“I’ve heard of accounts where mothers were told quite clearly that it was their fault,” said Donna Ockenden. “And heard from fathers who have carried a tremendous amount of guilt that they should have been able to stand up for their wives and partners. And what I say to them is, it isn’t your guilt to carry.”
One recurring theme the Ockenden team picked up on was a failure by staff to properly monitor the baby’s heart rate. The problem raises significant questions for all NHS bodies charged with overseeing trusts because the issue was highlighted as a problem at the Shropshire trust as far back as 2007.
After the failure had been noted as a contributory factor in two babies being born with severe brain damage, in 2004 and 2005, the Healthcare Commission, the regulator at the time, wrote to the trust demanding action to ensure the problems “are not repetitive and that learning is taking place”. But there’s no evidence the regulator followed up, with repeated catastrophic consequences:
- September 2014, Kelly Jones had stillborn twins, Ella and Lola, after the trust failed to properly read and interpret their heart rates.
- 4 December 2015, Graham Scott Holmes-Smith was stillborn. The trust accepted they’d failure to monitor the foetal heart rate.
- 15 December 2015, Ivy Morris was born with a severe brain injury after staff monitored her mother’s heart rate rather than Ivy’s and failed to spot she was in distress. She died aged four months.
Despite the errors, the new regulator, the Care Quality Commission (CQC), didn’t pick up on the problem. Its reports, following inspections of the trust in October 2014 and December 2016, make no mention of a problem with monitoring baby’s heart rates. It wasn’t until November 2018, when the CQC rated the trust as inadequate, that the need for training in monitoring baby’s heart rates is mentioned.
Chief Inspector of Hospitals at the CQC, Professor Ted Baker, robustly defended his organisation’s handling of the trust. “The families of Shrewsbury and Telford have been really important in driving forward the improvements,” he told Panorama. “The regulators identified problems in the maternity service and have subsequently taken enforcement action. I don’t accept that [we didn’t spot the problems].”
In a statement, the trust told the BBC they took “full responsibility” for the failings in maternity care. “We offer our sincere apologies for all the distress and hurt we know this caused.
“Apologies alone are not enough and must be backed up with clear and meaningful action. We have made strong progress, including significant investment in additional staff and staff training. We have completed more than 80% of the recommendations in the interim Ockenden Report.”
They added that the term High Risk Case Review is “no longer used”, adding that its “aligning” its investigation systems with those “being developed across the NHS in England.”
The sheer scale of the maternity errors in Shropshire means the well of grief may run deeper here, but it’s not the only area to have failed women and babies. In recent years, independent investigations have been ordered into maternity services in Cumbria, East Kent, Nottingham and South Wales.
Since 2017, the CQC has been rating the safety of maternity services in England. Its latest figures show that 41% of units need to improve their safety, while just 1% are rated as outstanding. The CQC says the rate of improvement is not good enough and Jo Mountfield, vice president of the RCOG, says it’s “probably” because the patients are women. “I think women’s health and research in this country should be given much higher priority. I think women’s voices need to be heard much more loudly.”
The interim Ockenden report led to a near £100m investment in maternity services in England. NHS England wrote to all health trusts last week telling them to no longer limit the number of caesarean sections they offer women. They also said they were committed to providing safe, compassionate maternity services.
The publication of the final report by Donna Ockenden next month will be a watershed moment in the history of the NHS – the revelation of multiple instances of maternity failures in a rural corner of England. Pippa Griffiths and Kate Stanton-Davies lived fewer than 40 hours between them, but their legacy, in terms of improved maternity care, could last decades.
Photographs by Phil Coomes