FAQs on maternity care at the Shrewsbury and Telford hospital NHS Trust

What is the investigation and why is it happening?

The Shrewsbury and Telford Hospital (SaTH) NHS runs the Royal Shrewsbury Hospital in Shrewsbury and the Princess Royal Hospital in Telford and includes five midwife-led units.

The trust is being investigated primarily about maternity care provided from 2000 onwards, although some limited earlier care is being considered. The investigation followed a number of clinical incidents, beginning with a new born baby who sadly died in 2009 in an incident which was not managed, investigated or acknowledged appropriately by the trust at the time[1].

The investigation began in 2017 and its original objective was to consider the quality of investigations into the incidents and implementation of their recommendations. It looked at alleged avoidable scenarios such as:

• deaths of babies soon after birth (neonatal deaths)
• deaths of mothers during and after birth (maternal deaths)
• mothers who experienced physical and psychological trauma as a result of the management of their labour
• stillbirths
• babies being harmed in the period after birth
• babies who suffered brain damage from the management of their birth, their care shortly after birth or during the neonatal period. For example, damage resulting from the management of infections such as Group B Strep.

After the original investigation began, many more families came forward with concerns about their care and the scope of the review was extended. This is set out in more detail in our article: The Shrewsbury and Telford Hospital Trust maternity review: a timeline of events leading to a police investigation into maternity care (penningtonslaw.com).

What did the interim report on maternity care at Shrewsbury and Telford NHS Trust reveal and why was this released ahead of the main report?

The interim report from Donna Ockenden, a senior midwife and community activist commissioned in 2016 to chair the independent review, and her team was released in December 2020. The aim of this was to ensure that patient safety was prioritised and dealt with expeditiously while the now large and complex investigation continued.

The extensive interim report was 37 pages long and a full summary of findings is set out in our article: Interim report on maternity care at Shrewsbury and Telford NHS Trust: a summary of findings (penningtonslaw.com).

The immediate recommendations from the report included:

• the need for better strategic oversight of the care provided
• women and their families must have a voice in the delivery of their care
• the different teams supporting mothers-to-be and newborn babies (midwives, obstetricians, obstetric anaesthetists and neonatologist) must be better integrated to provide a joined-up service
• complex pregnancies must be identified, risk-assessed and correctly managed
• there must be a continuing risk assessment throughout the pregnancy – if a mother-to-be begins her journey as a low-risk patient, midwives must be on guard to identify changes that increase that risk and alter her care accordingly
• the monitoring of babies’ heartbeats in labour needs to be significantly improved
• pregnant women must be given the correct information to make informed choices about their mode of birth.

What are the perceived underlying causes of the difficulties at the Trust?

The issues at the trust were multifaceted, as the interim recommendations indicate. These challenges were scrutinised in greater detail in the BBC Panorama programme – BBC One - Panorama, Maternity Scandal: Fighting for the Truth, which aired on Wednesday, 23 February 2022.

Investigations into care at the trust show that there was an apparent focus on natural birth which contributed to some of the problems, as the trust was praised for its low caesarean section rates. This was not the only cause of difficulties as there were also significant issues  about the monitoring of babies’ heartbeats. Concerns were voiced on this issue as far back as 2007[2], when the NHS regulator raised this with the trust.

Internally, there was a failure to properly investigate when things went wrong and the opportunity to learn from these errors was, therefore, lost. There also appears to have been a difficult culture internally at the trust.

What constitutes negligent maternity care?

There are very strict legal rules surrounding the assessment of care and deciding whether this is negligent. These take into account that, even with correct care, some people will sadly come to harm and some tragedies are unavoidable.

A patient’s care during labour is managed by midwives and obstetricians and, following the birth, a baby’s care is managed by midwives, obstetricians and neonatologists (doctors who care for babies who have become unwell). These midwives and doctors are expected to provide care to a reasonable standard. When the care provided falls below this standard and harm is suffered as a result, a person is entitled to bring a legal claim for negligence and to receive financial compensation for the harm they have suffered.

What can I do if I have concerns about the maternity care that I or someone close to me has received?

If you are concerned about the maternity care you or a loved one has received, please contact us. We can talk to you about the options available and help you decide from a place of knowledge whether bringing a claim for compensation is the right way forward for you.

When bringing a medical negligence claim it is important to obtain advice from specialist solicitors as this is a very complex area of law, where law and medicine overlap. 

The clinical negligence group at Penningtons Manches Cooper is regarded as one of the leading specialist medical negligence teams in the country. All senior members of the team are accredited specialists with either Action against Medical Accidents (AvMA), the Law Society or the Association of Personal Injury Lawyers (APIL).

The team and individuals are ranked in the top tier for clinical negligence in the two main legal directories – The Legal 500 and Chambers UK – and are accredited by APIL, the Brain Injury Group, Headway, Scope and the Spinal Injuries Association (SIA).

For further information, please call us on 0800 328 9545, email clinnegspecialist@penningtongslaw.com or complete our online assessment form.

[1] Ockenden Review – Terms of Reference Terms of Reference for the Maternity Review | Ockenden Maternity Review

[2] Shrewsbury trust warned over baby heart monitoring in 2007 - BBC News

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