What happened between Shrewsbury and Telford to cause so many babies to die between 2000 and 2019 in public hospitals and birth centers in these two Midlands towns, north of Birmingham? According to the damning conclusions of an independent report published on March 30, 201 babies died over twenty years (131 were stillborn, 70 died within seven days of their birth), 9 mothers also died and 94 babies are born with serious neurological sequelae, tragedies all considered avoidable, for establishments accounting for between 4,000 and 5,000 births per year.
For years the families went unanswered and no one has yet been convicted in what the horrified British media dubbed “the biggest scandal in the history of the NHS” – the UK healthcare system. Donna Ockenden, the highly respected midwife who conducted the survey for five years, describes frankly serious and repeated dysfunctions: lack of staff, lack of dialogue between midwives and doctors, lack of listening and compassion for parents, obsession with natural births with low use of caesarean sections – Shrewsbury and Telford were proud to have one of the lowest caesarean section rates in the country (14% in 2005, against a national average of 23.2% in the time).
“Throughout the different stages of care, the survey identified non-compliance with national clinical recommendations, whether for monitoring fetal heart rate, maternal blood pressure, management of gestational diabetes or resuscitation. . This, combined with delays in decision-making in the event of a problem and the inability to work between trades, has led to the many accidents, such as sepsis, encephalopathy and, unfortunately, death”, explains the report.
“I remain concerned”
Donna Ockenden goes further and paints a disturbing picture of the state of care in English maternity wards. “I remain concerned as NHS maternity services continue to fail to learn from the serious events taking place there,” she points out in her report. Interviewed as part of the BBC’s Panorama investigative program, broadcast in February, Jeremy Hunt, the former health minister who gave the green light to the Ockenden report in 2017, observes that“we must not make the mistake of thinking that the problem is confined to Shrewsbury. I would not be surprised if there were other dysfunctions in other maternities in the country”. Independent inquiries are underway in Kent, Nottingham and South Wales. Ted Baker, chief inspector of the Care Quality Commission, the control agency for English hospitals, thus admits in the Panorama program that “41% of English maternity units need to improve the safety of their care”.
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