A MATERNITY unit in Shropshire was found to have failings so severe that as many as 40 babies died of preventable causes.
As revealed in a new episode of BBC's Panorama, the Shrewsbury and Telford Hospital NHS Trust was praised for having the lowest C-section birth rate in the country – but it was coming at a cost.
What happened in the Shropshire baby deaths scandal?
In 2016, two grieving mothers made contact with each other to build a case after they believed their newborns died unnecessarily due to incorrect advice from midwives.
Over the next four years, the maternity unit's failures were brought to light in a long clinical inquiry, published as the Ockenden report.
They found that as well as chronic under staffing, not unlike other NHS trusts, the hospital had actually been praised for their encouragement of natural births.
In a bid to "stop overmedicalising", the trust had received recognition for having the lowest rate for C-section births in the country.
But the investigation found that to some degree, this was at the expense of many baby's lives, who desperately needed medical intervention at the time of their birth.
Parents found that they were given the incorrect medical advice at a crucial moment, which led to the death of the newborn.
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Kayleigh Griffiths lost her daughter to an infection. After a home birth, in a frantic call to midwives, Kayleigh explained that her daughter Pippa was coughing up a brown liquid.
She was told repeatedly not to worry but Pippa died the next morning.
Rhiannon Davies was assessed as having a low-risk pregnancy and went to give birth at midwife-led birthing centre run by the Shropshire trust in Ludlow.
She reported her baby's movements as reducing in the run up to the birth and afterwards, her baby was showing clear signs of respiratory distress which were not picked up by the midwives.
But the nearest doctor was 45 minutes away and the newborn could not be saved.
How many babies died?
It's suspected that as many as 40 babies and dozens of mothers could have been saved from their complications by the Shropshire trust over a twenty year period.
An inquiry also found that 50 children were suffering brain damage at the hands of trust, but since then the number of families complaining of poor care has more than doubled.
The C-section rates were consistently 8-12 per cent below the average for England.
In some cases women had forced to undergo traumatic forceps deliveries, leaving babies with fractured skulls and broken bones.
What did the report find?
The Ockenden report found that the trust had a culture of denying women choice regarding their labour, which was largely at fault as well as serious staffing issues.
It said: “A typical quote during interviews was that ‘they didn’t like to do caesarean sections,’” adding: “Women who accessed the trust’s maternity service appeared to have little or no freedom to express a preference for caesarean section or exercise any choice on their mode of delivery.
“There was a culture within the Shrewsbury and Telford Hospital Trust to keep caesarean section rates low, because [that] was perceived as the essence of good maternity care in the unit.
"Overall there did not seem to be a consideration of whether this culture contributed to unnecessary harm.”
The trust's chief executive, Louise Barnett, told the BBC the trust was committed to always acting transparently, reporting issues, including in maternity, where they can be properly investigated.
She said: "However, as the report clearly sets out, we are constantly reviewing the measures and actions taken to ensure that we make further improvements in these areas."
She added: "The Badgernet paperless maternity record was introduced in our hospitals in August and we have already successfully enrolled 500 women onto the system."
She explained that measures to deal with issues around foetal development were already being put in place.
The trust was working with Badgernet developers to allow data to be entered electronically, she added.
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