What's the worst thing about Thursday’s Ockenden Review into the latest NHS maternity scandal, at Shrewsbury and Telford Hospital? Is it the scale of the trauma, the deaths and the lack of compassion which put together make for the worst maternity scandal that the health service has ever seen? The inquiry started with 250 cases, but widened that to a horrifying 1,862 cases where care may have been inadequate. These are just the interim findings as the investigation continues and will publish a final report in 2021.
“'The review team observed that women who accessed the Trust's maternity service appeared to have little or no freedom to express a preference for Caesarean section or exercise any choice on their mode of delivery.'
The individual stories are still more harrowing. Women were blamed for their babies' deaths, told the agony they were in was 'nothing' and midwives failed to monitor mothers in the birth centre because 'the unit was busy'. This is what happened in that last case:
“'When problems were eventually identified in labour there was a delay in transferring the mother to the labour ward, where her baby was delivered in very poor condition and hypoxic ischaemic encephalopathy was later confirmed. The baby subsequently died. The family were critical of the ensuing investigation and correspondence with the Trust, and said during a meeting with the Review Chair that they had been "put off, fobbed off and had obstacles put in our way".'
Or perhaps it's the fact that the Care Quality Commission had rated this Trust as 'good' in 2015, suggesting that a system of oversight that was supposed to have been beefed up following previous scandals still missed problems.
“'Today, the name of Morecambe Bay has been added to a roll of dishonoured NHS names that stretches from Ely Hospital to Mid Staffordshire. This Report sets out why that is and how it could have been avoided. It is vital that the lessons, now plain to see, are learnt and acted upon, not least by other Trusts, which must not believe that “it could not happen here”. If those lessons are not acted upon, we are destined sooner or later to add again to the roll of names.'
The report’s author, Dr Bill Kirkup, could not have anticipated the scale of the scandal that would follow Morecambe on that roll. This week’s review makes similar calls for what happened to never be repeated elsewhere, saying:
“'Having listened to families we state that there must be an end to investigations, reviews and reports that do not lead to lasting meaningful change. This is our call to action. We expect to see real change and improved safety in maternity services as a result of findings from these 250 case reviews and our resultant Local Actions for Learning and Immediate and Essential Actions whilst we continue to work towards completion of the full and final report.'
Will this be the last report on a maternity scandal in the NHS? Or just the latest?
James Titcombe wrote 400 letters as he tried to get justice for his son Joshua, who died after a catalogue of failings by staff at Furness General Hospital in 2008. He was frequently fobbed off by organisations across the health service who treated him as though he had merely been driven mad by grief, rather than someone who had spotted unacceptably inadequate care of mothers and babies. In Shrewsbury and Telford, it was Rhiannon Davies and Richard Stanton, who lost their daughter Kate six hours after she was born, and Kayleigh and Colin Griffiths, who lost their daughter Pippa at one day old. The two families had to mount their own investigations into what was going on at the maternity unit, eventually forcing an independent inquiry into the trust. It has taken them a decade to get justice.