April 2017 – An investigation is launched into a cluster of baby deaths at Shrewsbury and Telford Hospital NHS Trust
August 2018 – Scope of inquiry expanded to look at 40 cases between 1998 and 2017, then later to 100
November 2018 – The trust is placed into special measures after receiving its third CQC warning over staffing and safety concerns in four months
November 2019 – A report leaked to the Independent says babies and mothers died amid a “toxic” culture at a hospital trust stretching back 40 years
June 2020 – West Mercia Police said it was investigating whether there was “evidence to support a criminal case either against the trust or any individuals involved”
July 2020 – It is revealed the review is now examining more than 1,800 cases
Jeremy Hunt 10th December 2020: ”This is a tragic day for families across Shropshire, who’ve had it confirmed in black & white that hundreds of babies died needlessly. There’s nothing more cruel in life than losing a child,but to do so because of mistakes that were covered up makes things infinitely more painful”.
The interim report lists numerous traumatic birth experiences including the deaths of babies due to excessive force of forceps and stillbirths that could have been avoided.
Others recount repeated failures by staff to recognise mothers and babies in deteriorating conditions, including one mother whose baby died because staff were “too busy” to monitor her during labour.
It found letters and records “which often focused on blaming the mothers” rather than considering whether the trust’s systems were at fault. This was exacerbated by the attitude of staff, the report said.
It said: “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. ( as at Everglow Campaign evidence)
After each death “in some cases, no investigation was initiated” whilst in others “no learning appears to have been identified.”
The report said “inappropriate language had been used at times causing distress,”
This is not a dry report – its pages scream with the voices of the families who have been needlessly harmed.
I’ve heard many of these stories over the years, having spoken to dozens of families, but to read it in black and white, was still a sobering moment.
The review’s publication also draws a firm line under the pretence that successive poor, weak leaders of the organisation maintained until recently, namely that the trust was no worse than others. They are worse, much worse, and have been for years.
The alphabet soup of NHS organisations that were meant to protect these families – the inspectors, the regulators, the commissioners – have a lot of questions to answer too.
Their repeated refusal to see what was happening, despite being told of the problems, is just as shaming as the trust’s stance. Their moment of reckoning will come next year, when the final report is published.
Michael Buchanon Social Affairs Correspondent