Summary

  • A review into maternity failings at an NHS trust finds more than 200 babies may have died due to repeated failures

  • The report, led by senior midwife Donna Ockenden, follows a five-year investigation of Shrewsbury and Telford Hospital NHS Trust

  • Health Secretary Sajid Javid tells MPs that clinical details were kept on post-it notes that went into the bin with tragic consequences

  • The report found serious mistakes were repeated over decades and there was a failure to investigate and learn from infant deaths

  • A lack of transparency and honesty at the trust is highlighted and some staff described being frightened to speak to the review team

  • Kayleigh Griffiths, whose daughter Pippa died, says families had to fight all the way but have "finally been heard"

  • Rhiannon Davies, whose daughter Kate died, says the number of deaths "do not tell the whole story" of the impact on families

  • Trust chief executive Louise Barnett vows to make improvements and apologises for the pain and distress caused

  1. Thank you and goodbyepublished at 16:48 British Summer Time 30 March 2022

    That's the end of our live coverage for today, thank you for joining us.

    This page was edited by Jennifer Meierhans and Tom Warren.

    Updates were written by Andy Giddings, Francesca Gillett, Riyah Collins and Sophie Madden.

    You can read our latest story here and if you are affected by issues raised in this article, help is available through the BBC's Action Line.

  2. What's happened today?published at 16:42 British Summer Time 30 March 2022

    We will shortly be ending our live coverage on the UK's biggest maternity scandal at Shrewsbury and Telford Hospital NHS Trust. Here's what the report concluded:

    • There were repeated failures in the quality of care at the trust between 2000 and 2019. Mothers and babies died or suffered major injuries as a consequence
    • Staff were reluctant to perform Caesarean sections leading many babies to die during birth or shortly after, and there was ineffective monitoring of foetal growth
    • In many cases, mothers and babies were left with life-long conditions as a result of their care. Some babies suffered skull fractures, broken bones or developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries
    • The health trust has apologised to affected families and described the report as "deeply distressing". It said many changes highlighted by Ms Ockenden had already been introduced
    • Health Secretary Sajid Javid said the trust, NHS and government accepted all 84 of the report's recommendations
    • Bereaved families gathered together to hear the findings. Kayleigh Griffiths, whose daughter Pippa died in 2016, said words from the trust "aren't going to be enough"

    You can read the latest story in full here

    Summary of findings
  3. Report the result of a long struggle for familiespublished at 16:31 British Summer Time 30 March 2022

    Families affected by maternity scandalImage source, PA Media

    Today's report is the biggest of its kind in the history of NHS maternity services is the result of a long struggle for many of the families affected.

    Some had campaigned for years to have their concerns listened to and refused to be dismissed by the Shrewsbury and Telford Hospital Trust.

    They were there to see Donna Ockenden present her findings this morning and Kayleigh Griffiths, who lost her daughter Pippa in 2016 said: "To finally be heart by Donna is a great achievement for all families."

    But she doesn't believe the fight will be over until the concerns raised in the report are taken on board by the trust.

    Both she and Rhiannon Davies, who lost her daughter Kate in 2009 were in tears after Ms Ockenden delivered her speech.

    And Ms Davies says: "This report can make a difference, this report could be a legacy, it should be."

    Read more: The mothers who helped uncover the biggest NHS maternity scandal

  4. Ockenden 'genuinely cares' says bereaved motherpublished at 16:25 British Summer Time 30 March 2022

    Hayley Matthews

    As the magnitude of today's report into baby deaths and maternity failings sinks in, one mother has paid tribute to its author Donna Ockenden.

    Hayley Matthews' son, Jack Burns, was 11 hours old when he died in 2015 after staff failed to spot he was suffering from a serious infection, Group B Streptococcus.

    "She genuinely cares, it is not another baby and another number, she genuinely cares about each and every one of us," Ms Matthews says.

    "As she says, we are her family."

    She was among the families who attended the publication of the review at the at Mercure Shrewsbury Albrighton Hotel, Shropshire.

    Ms Matthews says she is "shocked" by the report's findings but hoped lessons will be learned.

    "Telford and Shropshire as a whole isn't big, but the numbers that it has happened to, it is like probably half, it is disgusting and it should never happen again," she says.

  5. Watch: 'Today belongs to families failed by our trust'published at 16:17 British Summer Time 30 March 2022

    Here's the boss of the Shrewsbury and Telford NHS Hospitals Trust making a statement following the publication of the Ockenden report which detailed unprecedented failings in maternity care.

    Trust chief executive Louise Barnett "apologises fully" and says "we do have more to do".

    Media caption,

    Shrewsbury maternity scandal: Trust has 'more to do'

  6. Surprise at scale of problems at trust - birth charitypublished at 16:11 British Summer Time 30 March 2022

    Clea Harmer

    The head of a birth charity says there is "surprise" at the scale of the maternity report's inquiry.

    Clea Harmer, chief executive of stillbirth and neonatal charity Sands, says the inquiry has grown "enormously" since its launch in 2017 when it was begun to look at 23 cases.

    She says the charity is "very aware...how often parents aren't listened to, how often they aren't involved in reviews and how difficult and painful and devastating some of their experiences have been".

    The "most important message" to come out of this report is that parents must be listened to, she says.

    "That must change and not just at Shrewsbury and Telford but in every hospital, in every maternity unit," she says.

  7. National maternity bosses promise to 'redouble' effortspublished at 16:06 British Summer Time 30 March 2022

    Two senior NHS figures have promised to "redouble" efforts to improve maternity services around the country, in the light of the Ockenden report.

    Jacqueline Dunkley-Bent, England's chief midwifery officer and Matthew Jolly, national clinical director for maternity and women's health, say the families "should have been protected and cared for at the most special time in their lives".

    An extra £127m has been committed to "boost our workforce, strengthen leadership and improve culture" they say.

  8. Staff are encouraged to speak out - hospital bosspublished at 16:00 British Summer Time 30 March 2022

    The chief executive of the Shrewsbury and Telford Hospital NHS Trust, says she encourages staff to speak out about any concerns after the report highlighted some feared the consequences.

    Asked about staff comments made to the inquiry claiming they had been told not to participate she says it is "very committed to our culture change programme".

    "We have made progress," Ms Barnett says.

    "We have more colleagues contributing their ideas and also raising concerns, which we are acting on within the organisation," she says.

    "But we do have more to go, and if any person or any member of staff has any concerns, I would really encourage them to raise it through the many routes we have available... so that we can absolutely act on those issues."

  9. Hospital staff spoke of a culture of bullyingpublished at 15:44 British Summer Time 30 March 2022

    We've been hearing that Donna Ockenden's team found it difficult to get hospital staff to speak to them.

    A process whereby staff could speak to the review team heard “that there was a culture of bullying within the leadership team,” that wasn’t confined to maternity services.

    Another said, “its very hard to speak up because despite what anybody will tell you, there are consequences”.

    “You feel like you are penalised constantly. I’m keeping my head down,” said another medic, while a fourth remarked that “I feel there’s a reluctance to change there.”

  10. I told them I was unwell but they didn't listen, says mumpublished at 15:31 British Summer Time 30 March 2022

    Emma Priddey

    Throughout the day we've been hearing from families affected by today's report.

    Emma Priddey has told the BBC how she nearly died after giving birth to twins in 2019 at the Princess Royal Hospital, in Telford.

    Ms Priddey says she was told to continue with a natural birth despite her son being breech.

    "I remember asking three times, one of them whilst I was pushing. When I was pushing I remember asking the consultant, 'are you sure that it's OK to go ahead with this?' and they said, 'yeah he'll turn'.

    "But what I wasn't aware of was as a twin mum it is my right to choose whether I have a C-section or go naturally," she says.

    'I nearly died'

    Ms Priddey had an emergency c-section and says she became unwell very quickly afterwards.

    "Throwing up, couldn't hold my babies. I don't remember the first few days of their life. Despite all of my family's efforts and my efforts to tell the team that were on how unwell I was, I just wasn't listened to.

    "Just short of 48 hours later I had to be rushed back in for major surgery for which they realised I had a mass bleed on the uterus and the only way to save my life was to have a hysterectomy."

    If you are affected by any of today’s news, help is available through the BBC’s Action Line.

  11. What's been said about the Ockenden report?published at 15:23 British Summer Time 30 March 2022

    Donna Ockenden with the reportImage source, PA Media

    If you're just joining us or need a recap, here's a look at the reaction to a major report into baby deaths and maternity failings at a hospital trust.

    The report: The Ockenden report is the conclusion of an inquiry, first launched in 2017 to examine concerns over maternity care at Shrewsbury and Telford Hospitals NHS Trust (SaTH).

    The findings: The report outlines how failures led to the deaths of more than 200 babies, nine mothers and left other infants with life-changing injuries, with deaths often not investigated and parents not listened to.

    The families: In total, the inquiry has looked at almost 1,600 cases, including that of Kayleigh Griffiths, whose daughter Pippa died in 2016 at 31-hours-old from a Group B Streptococcus infection. Mrs Griffiths was instrumental in securing the inquiry and says it is "so important that the learning is taken" from the report.

    The hospital trust: Louise Barnett, chief executive of the trust, says it offers its "wholehearted apologies" to the families affected and says it will continue to make improvements.

    The health secretary: Sajid Javid told MPs vital clinical information was kept on post-it notes and swept into a bin "with tragic consequences for a newborn baby and her family". He vowed to "act swiftly so no families have to go through the same pain in the future".

    The police: Operation Lincoln, West Mercia Police's investigation to explore whether there was evidence to support a criminal case against the trust or any individuals involved, is ongoing, with Det Ch Supt Damian Barratt adding it will feed "appropriate elements" from the report into its work.

  12. We failed to make ourselves heard - hospital staffpublished at 15:11 British Summer Time 30 March 2022

    Donna OckendenImage source, PA Media

    Donna Ockenden has spoken of the difficulties her team faced in getting staff to speak out in order to contribute to the report.

    She says: "Staff have described to us they were frightened to speak to the maternity review team and were advised by trust managers not to participate in the Staff Voices initiative."

    Staff Voices is the listening exercise set up by the Ockenden team.

    One member of staff, who came forward earlier this month, told the team: "If I could say anything to the families it would be that there were people who tried to make changes.

    "We tried to escalate our concerns and be heard, but every process we used was set up not to acknowledge our voices or the problems we were highlighting.

    "We were ignored and made out to be the problem. But ultimately we failed to make ourselves heard."

  13. Report a 'watershed moment' says council leaderpublished at 14:57 British Summer Time 30 March 2022

    Shaun DaviesImage source, Telford and Wrekin Council

    The Ockenden report has been described as a "watershed moment" by the leader of one local authority in Shropshire.

    Shaun Davies, from Labour-run Telford and Wrekin Council, says he is in regular contact with the leadership at the Shrewsbury and Telford Hospital Trust, "seeking assurances that they are implementing changes".

    He says he recognises "considerable strides" have been made to maternity care in the county since the publication of Ockenden's interim report, but more investment is needed.

    And he believes that's not just in maternity, that's across hospital services in the county.

  14. What is the current guidance around Caesareans?published at 14:46 British Summer Time 30 March 2022

    Media caption,

    Caesarean sections: Why and when are they used?

    Among the failures highlighted in today's Ockenden report is about the Shrewsbury and Telford trust's stance towards Caesarean sections. The report says there was a reluctance to perform Caesareans, which led to many babies dying during birth or shortly after.

    Until last month, maternity units in England were encouraged to promote natural births and keep the Caesarean rate to about 20%.

    But in February the guidance was changed - and now the NHS in England no longer limits the number of Caesarean sections it performs, under plans to improve care for mothers and babies.

    Maternity staff have been told to treat cases on an individual basis and follow National Institute for Health and Care Excellence guidance , externalallowing women to opt for a planned Caesarean even if it is not for medical reasons.

    If a woman wants to have a caesarean, a trust must try to grant their wishes, and only say no if they have a good, evidence-based reason.

    Health Secretary Sajid Javid also referred to the issue in his Commons statement earlier. He said it was right that doctors' groups - the Royal College of Obstetricians and Gynaecologists, and the Royal College of Midwives - had since said they regretted their campaign pushing for natural births.

  15. Police continue to explore possibility of criminal casepublished at 14:29 British Summer Time 30 March 2022

    West Mercia Police station in TelfordImage source, Google

    While the Ockenden report has finally drawn to a conclusion, the police investigation into actions in Shropshire is still under way.

    West Mercia Police provided an update today to say it's still trying to determine whether there is enough evidence to support a criminal case against the Shrewsbury and Telford Hospital Trust or any individuals involved.

    It described its own investigation, which also started in 2017, as "highly complex" and said so far no arrests had been made.

    The findings of the Ockenden report will now be fed in to its own inquiry, the force said.

  16. 'They're not just taking people's babies, they're taking away Christmases, birthdays'published at 14:08 British Summer Time 30 March 2022

    Kye Hall was four days old when he diedImage source, Phil Coomes
    Image caption,

    Kye Hall was four days old when he died

    One of the mothers who lost a baby at the trust is Katie Anson, whose son Kye Hall died in 2015 aged four days.

    Staff failed to properly take or read heart-rate readings which meant they didn't spot Kye was in distress.

    "You feel robbed," says Katie. "It makes me angry, but it makes me sad as well. To think of all the people who've lost their children because they haven't done anything, they haven't acted."

    In a similar case, Graham Scott Holmes-Smith was stillborn in 2015. Midwives didn't realise he was in distress because they failed to read his heart-rate monitor properly.

    "They're not just taking people's babies away, they're taking away Christmases, birthdays, everything," says mother Sophie Holmes.

    More here.

  17. Call for 'sustained investment' in trainingpublished at 13:55 British Summer Time 30 March 2022

    Maternity bed at Princess Royal Hospital, Telford

    The Nursing and Midwifery Council is looking for "sustained investment in continuing professional development" of midwives, following the publication of the Ockenden report.

    Andrea Sutcliffe, its chief executive and registrar, says: “Safe care for mothers and babies happens when maternity services have a fair culture, strong multidisciplinary relationships and an open approach if there’s a concern."

    She also says it's important to know "when things are going wrong" and people take the correct response.

  18. This is 200 pages of harmed families, says bereaved motherpublished at 13:41 British Summer Time 30 March 2022

    Kayleigh GriffithsImage source, Phil Coomes
    Image caption,

    "Last night I couldn't sleep, my anxiety was through the roof," says Kayleigh

    Kayleigh Griffiths, whose daughter Pippa was one-day-old when she died in 2016 after midwives failed to spot an infection, has responded to the report.

    Kayleigh was one of the first mothers to publicly raise concerns - and you can read more about her role in uncovering the scandal here.

    "It's so important that the learning is taken," she says. "This is 200-odd pages of harmed families... It's really important, and it's really important that maternity services up and down the country read this and listen to what families have gone through and the impact that's had on people's lives."

    Asked on how proud she must feel to have come this far, Kayleigh Griffiths says it's difficult to comprehend. Her partner Colin adds: "It's bittersweet. It's an accomplishment, but it didn't need to happen. It shouldn't have happened in the first place."

    "We visited Pippa this morning before we came, and we said 'this is what we've done for her'," says Kayleigh - who says she's suffered from PTSD. "It's just heartbreaking."

    "We've had to fight all the way along in this, so to finally be heard by Donna is a great achievement for all families. But I don't think we've been heard by the trust yet. That's the really important thing we need from this - that the trust need to recognise that words aren't going to be enough."

  19. The report's findings at a glancepublished at 13:36 British Summer Time 30 March 2022

    The session on the Ockenden report in the House of Commons has now come to an end.

    Here's a reminder of some of the figures highlighted by today's report before we hear more from the families affected.

    Graphic on report's findings
  20. Hunt asks when we will see action on report findingspublished at 13:27 British Summer Time 30 March 2022

    Jeremy Hunt

    Jeremy Hunt, the former health secretary who commissioned the Ockenden report, asks Sajid Javid when action will be taken as a result of it.

    Hunt calls for "a culture in the NHS that is open, transparent accepts things go wrong, but hungry to learn from mistakes so that we never again repeat tragedies like this."

    Javid says he has asked for a timetable on the implementation of the report's calls for action.

    "I want to see that done as quickly as possible," he says.