Systemic change to prevent another
NHS maternity scandal won’t happen
until mothers are heard, says Saskia Murphy

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Every so often a story hits the headlines that stops you in your tracks. Last week’s report into the deaths of women and babies at hospitals under Shrewsbury and Telford NHS Trust is one such story – a story of denial, cover-ups, of families being silenced and ignored, of women and babies suffering death and life-changing injuries that in most cases could have been avoided.

The Ockenden Report, published after a five-year investigation, found more than 200 babies may have died due to repeated failures by the trust. The report also found nine mothers died as a result of poor care and 94 children suffered avoidable brain damage.

Senior midwife Donna Ockenden, the report’s author, said mothers were denied caesarean sections and forced to suffer traumatic births due to a fixation with hitting “normal” birth targets. Some babies sustained skull fractures or broken bones after traumatic forceps deliveries.

Ockenden’s investigation swelled to include a staggering 1,862 cases from 2000-2019, becoming the biggest maternity scandal in NHS history. The report reveals a shocking lack of staff, training and oversight of maternity wards.

Last Wednesday, the day the report was published, broken-hearted parents came forward to share their stories. Many of them had previously thought they were alone in their grief, that they and their babies were the victims of one-off tragedies.

But Ockenden’s report shines a light on failures spanning decades. Instead of investigating serious incidents or learning from mistakes, Ockenden said the trust tended “to blame mothers… in some cases even for their own deaths”.

The report calls for immediate systemic change across the NHS, including funding to relieve pressure on understaffed maternity wards.

But for families who returned home to empty cots, who held funerals for babies who lived for just a few hours, who packed away newborn-sized clothes before they’d been worn, the report’s recommendations will no doubt be too little too late.

A common theme runs through the testimony of mothers who lost babies under the care of the trust. Many of them knew something wasn’t right, but medical professionals failed to take their concerns on board. Rhiannon Davies, whose daughter Kate died in March 2009 at just six hours old, was told she had a “lazy baby” when she expressed concerns over reduced foetal movement in the days leading up to the birth. Kayleigh Griffiths, who had decided on a home birth for her second child in 2016 because of what she described as the “appalling state” of the birthing centre in Shrewsbury, spoke to her midwifery team on four occasions about her concerns over her newborn daughter Pippa, including a frantic call at 3am after she coughed up brown liquid. She was repeatedly told not to worry. Pippa died at just one day old.

In 2020 the Cumberlege inquiry found lives had been ruined because officials failed to hear the concerns of women given drugs and procedures that caused them or their babies considerable harm. And now Ockenden’s report reveals a culture where women were shamed, belittled, silenced and blamed for trying to advocate for themselves and their babies in their most vulnerable moments.

There are rightly calls for lessons to be learned. But systemic change cannot happen until women and mothers are listened to.

Saskia Murphy is a Manchester-based freelance journalist. Follow her on Twitter @SaskiaMurphy

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