London 30th March 2022: The final report of the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust is shocking and heart-breaking to read. The lost opportunities to learn from mistakes, blaming women for failures in care, and a culture of not listening to families involved.

While many thousands of babies are born safely in England each year, we’re appalled to have heard today from Donna Ockenden, Chair of the Independent Maternity Review, that as recently as this month, staff members from The Shrewsbury and Telford Hospital NHS Trust were contacting the Review to voice their concerns with safety concerns about maternity care at the trust. The Review has been ongoing for the last five years, has investigated 1,592 clinical incidents that occurred between 1973 to 2020, already made several recommendations for change, and yet it would appear things have not changed.

The arrogance of staff, repeated failure to properly investigate serious incidents, and failure to learn from the investigations that were carried out uncovered but the Review, are appalling. But these characteristics have been noted in other investigations into safety failings in the NHS.

Listen to patients

The persistent failure of clinicians to listen to patients and their families simply has to stop. Time and time again, investigations into serious failings in care in the NHS show that when midwives, nurses and doctors do not listen to what patients are telling them, catastrophes follow.

We’re also appalled that this uncaring culture was able to continue unchallenged for so long. Not only was the Trust not thoroughly investigating clinical incidents, but outside bodies that reviewed the Trust and found that maternity care was substandard, were unable to improve the service. The failure of regulators and others to effect change over 20 years is a matter of concern to us.

We applaud the 1,486 families who took part in this review; reliving the events must have been exceptionally difficult. We want to pay tribute in particular to the courage and persistence of Rhiannon Davies and Kayleigh Griffiths, bereaved mothers whose quest for answers triggered this review. They should not have had to fight so hard to understand what happened to them and their children.

We very much hope that Ockenden’s immediate and essential actions for all maternity services in England will be acted on, so that no family will ever again have to fight for answers as to what has happened when something goes wrong during childbirth.

Kindness and compassion needed

Among the immediate and essential actions we welcome: the insistence that investigations are written in language that families will understand; better care of bereaved families; and better postnatal care for unwell mothers. We also believe that the Review’s findings make it clear that those caring for pregnant women and women in labour must work in partnership with their patients, practice shared decision making, listen to them, and treat them with respect, kindness, and compassion.

Learning of the bullying culture at the Shrewsbury and Telford NHS Trust, in which staff members were afraid to speak up about safety concerns and were told not to cooperate with the Review, makes it easy to see how the same Trust was able to treat so many families without the respect they deserved.

As an organisation that speaks up for patients, we have read many reports that have raised many of the points the Ockenden Report raises today, only to see little or no change. This time positive changes must be made, the culture in maternity units must change, families must be listened to, and women in labour must be kept safe from harm. And, if things do go wrong, no family should have to fight like Rhiannon Davies and Kayleigh Griffiths to get the answers they need.