Shrewsbury bosses who are STILL profiting from NHS after dismissing mothers’ concerns

2

View
comments

NHS bosses who oversaw the worst maternity care scandal in British history and who dismissed mothers’ concerns as ‘scaremongering’ are still profiting from jobs in the health service, including one manager who lied on his CV to get the job.

A damning five-year inquiry, published yesterday, revealed 201 babies and nine mothers died needlessly during a two-decade era of appalling care at the Shrewsbury and Telford Hospital NHS Trust between 2000 and 2019.

Mothers were found to be frequently blamed by staff for the care they received and in some cases their even own deaths. 

Author the inquiry, midwife Donna Ockenden, has warned that childbirth in England will be unsafe until the lessons learnt from the largest maternity care scandal in Britain’s history are learned.

The findings prompted Health Secretary Sajid Javid to yesterday say the individuals responsible for the serious and repeated failures at the trust will be ‘held to account’ 

Mr Javid also revealed yesterday that police are now investigating 600 cases related to poor care at the trust. 

It comes as further reviews of potentially substandard maternity care in Nottingham and East Kent are underway. 

Parents responsible for bringing the inquiry to reality have also warned that the failings they experienced are probably not unique to Shrewsbury and Telford Hospital NHS Trust. 

But it has been revealed today that five former bosses in charge of the trust during the periods of poor care went on to enjoy further careers in healthcare, with four profiting from the NHS.

One was even found to have lied on his CV faking a University degree to get the £112,00 a year position at Shrewsbury and Telford Hospital NHS Trust.

Many of them were allowed to leave the trust without sanction and walk into other lucrative jobs within the health service or work as consultants for private companies with multi-million pound contracts with the NHS. 

The most recently departed chief executive Simon Wright, 54, who took on the role in 2015, left his £160,000 role in 2019 just as the scale of the care sandal at the trust was emerging.

He then took up a position at a US healthcare firm handed millions in UK Government contracts. 

Mr Wright was hired as a ‘continuous improvement consultant’ by the Seattle-based Virginia Mason Institute, awarded a £12.5million contract by ministers in 2015.

Under the five-year scheme, the US hospital was asked to drive up standards at five trusts, ironically including Mr Wright’s former Shrewsbury and Telford.

He has admitted the Trust delayed publishing a Royal College of Obstetricians and Gynaecologists’ (RCOG) critical report of maternity services at the trust and even sent a delegation of staff to London to persuade the authors to write a more positive addendum, delaying publication by 12 months. 

This prompted cries of a ‘cover-up’ from families of those who died or injured as a result of poor care at the trust.  

During his time as chief executive a baby called Pippa Griffiths died shortly after being born while being cared for by Shrewsbury staff in 2016. Her parents would go to join others in seeking answers as to why their baby died. 

Mr Wright also accused the Daily Mail of ‘scaremongering’ over the scale of care failings at his trust in 2018 when the newspaper published an article on its front page detailing, at the time reports of 60 baby and mother deaths due to poor care. 

He was also head of the trust when then health secretary Jeremy Hunt ordered the original inquiry to investigate 23 cases of poor care. It would later be expanded to encompasses hundreds of cases.  

Another chief executive, Neil Taylor narrowly avoided jail in 2005 after hospital bosses discovered he had lied to get the top job.

Mr Taylor, 59, had run the Royal Shrewsbury Hospital for four years when he produced a fake degree certificate in a bid to land the £112,000 chief executive role at the new Shrewsbury and Telford Hospital NHS Trust when it merged with the Princess Royal Hospital in Telford in 2003.

In reality, he had just one or two A-levels and admitted obtaining a pecuniary advantage by deception.

He plead guilty in 2005 to one charge of obtaining a pecuniary advantage by deception and one charge of attempting to commit the same offence.

Mr Taylor has since been a director of MDT Health Consulting which is paid by NHS trusts to advise them on digital healthcare solutions. 

He was succeed by Tom Taylor, who was top boss at Shrewsbury between 2004 and 2010 and still works for the NHS today. 

During Mr Taylor’s tenure the then health regulator, the Health Care Commission warned there were issues in how staff were monitoring foetal heart rates at the trust after incidents where babies were injured.

He was also in charge in 2009 when Kate Stanton-Davies died just hours after being born while under the care of Shrewsbury staff. Her parents’ campaigning would go on to spark the Ockenden inquiry. 

Mr Taylor is now chairman for NHS Counter Fraud Authority, a taskforce responsible for uncovering financial wrongdoing in the health service.   

Adam Cairns then took the reigns at the trust from 2010 to 2012 before taking a healthcare position in Doha in Qatar. 

He was replaced by Peter Herring who ran Shrewsbury until 2015. Mr Herring controversially retired from the position in 2014 for one single day, claiming a tax-free payment of £252,000 pounds in doing so, before returning to his old job 24-hours later. 

During his time maternity services at Shrewsbury faced an internal investigation in 2013, but it concluded it was ‘safe’ and of ‘good quality’.

Mr Herring has also previously expressed regret about a decision to not investigate the death of Kate Stanton-Davies. 

After departing Shrewsbury he went on to serve in a variety of senior positions at NHS trusts, including Kings College London Hospital NHS Foundation, Sherwood Forest NHS Trust and University College London Hospital.

Some of the former hospital bosses have expressed ‘regret’ and ‘sadness’ over the events detailed in Ms Ockenden’s report. 

It comes as the author of a report into Britain’s worst maternity scandal said pregnant women will not be safe to give birth until her full raft of recommendations are implemented.

Ms Ockenden said it was ‘astounding’ that ‘systemic’ failings at Shrewsbury and Telford Hospital NHS Trust happened for so long.

She added ‘maternity services cannot provide safe and effective care’ without a new ‘blueprint’ for care for mothers and babies and proposed 15 ‘immediate and essential’ steps for every NHS maternity ward to take, including better training and better communication with families.

Richard Stanton, whose daughter, Kate, died in 2009 as a result of what he described as the trust’s ‘abhorrently poor care’ warned other the type of failures his family experienced were not limited to just one trust.

He told the Daily Telegraph: ‘I don’t think Shrewsbury and Telford is an isolated case. I think they’re an extreme case in terms of where they are in numbers. That doesn’t mean this isn’t happening anywhere else.’

Health leaders have also warned that babies and mothers are being put at risk in England over a shortage of midwives.   

The number of midwives employed in the NHS in England has fallen to 26,901 according to figures published last month.

This is down from 27,272 a year ago, with the Royal College of Midwives warning it adds to an existing shortage of 2,000 staff.  

Yesterday’s report said an obsession with ‘normal births’ contributed to the biggest maternity scandal in NHS history. 

Ms Ockenden blamed eight external bodies in part for allowing the litany of errors that resulted in 201 babies and nine mothers dying in avoidable circumstances.

In one case the Care Quality Commission, which regulates the NHS in England, had even rated the maternity ward at the Trust as ‘good’.

Ms Ockenden’s report uncovered 1,592 times that women and their babies died or were left disabled or traumatised by their experiences at the Trust.

She said the Trust had come ‘to blame mothers… even for their own deaths’. 

The devastating report said some women were forced to have vaginal births when they should have been offered a C-section– all because natural birth zealots wanted to keep surgery rates low.  

The landmark 250-page report found the trust presided over catastrophic failings for 20 years, ignored the concerns of parents and did not learn from its own inadequate investigations. 

This led to babies being stillborn, dying shortly after birth or being left severely brain damaged.

Some infants suffered skull fractures, broken bones or developed cerebral palsy after traumatic forceps deliveries. Others were starved of oxygen and had life-changing brain injuries.

The inquiry’s examined cases involving 1,486 families from 1973 to 2020 and reviewed 1,592 incidents. 

A total of 201 babies and nine mothers were found to have needlessly died with 94 other children suffering brain damage due to the traumatic nature of their birth. 

The report also detailed how mothers themselves were frequently blamed for their own deaths.

In one incident in 2011 a husband was told his wife’s death had been due to her ‘size’.

‘[it was] difficult for the midwives to listen to baby’s heart beat due to her size,’ he was told. 

In another case, this time in 2002, trust documentation into the death of a mother noted: ‘She must have been responsible for some of that because she clearly did not complain very much and tended to ignore many of her symptoms.’ 

Ms Ockenden also warned that staff were still expressing concerns about the trust – and issued 15 ‘immediate’ actions for all maternity services in England amid fears of similar failings elsewhere.

Bereaved mothers Rhiannon Davies and Kayleigh Griffiths, who spearheaded calls for the inquiry after their daughters’ deaths, hugged yesterday as they welcomed the findings.

But Mrs Griffiths, whose daughter Pippa died avoidably in 2016, said: ‘This is 200-odd pages of harmed families. It’s a disgrace that they haven’t learned when we’ve told them what the issues were.’

Mr Stanton and Ms Davies often wonder what kind of girl their firstborn, Kate, would have grown up to become.

‘She would have been 13 on March 1 and you think, ‘What clothes would Kate be wearing today? What music would she like?’ Mr Stanton, 52, said. 

‘All our lives would have been drastically different if Kate was alive. She should be here today because her death was completely avoidable.’

Kate died in her father’s arms just six hours after she was born at a mid-wife-led unit in Ludlow, Shropshire.

Since that day in 2009, her parents have fought tirelessly to expose what Mr Stanton describes as the trust’s ‘abhorrently poor care’.

He believes the trust’s obsession with natural birth impacted his wife’s care and says she should never have been near a midwife-led unit.

‘As parents, we were ignored, fobbed off, treated like we were the problem – just noisy people with an axe to grind,’ he says.

‘You never get over the loss of a child. You only learn to live with it.’

The report found that:

One in four of the 498 stillbirths reviewed had ‘significant or major concerns’ over the maternity care given;There were 29 cases where babies suffered severe brain injuries and 65 cases of cerebral palsy;Twelve deaths of mothers were investigated, none of whom received care in line with best practice at the time;Some women were blamed for their own deaths, while incidents that should have triggered a serious incident investigation were ‘inappropriately downgraded’;Midwifery staff were ‘overly confident’ in their abilities, and there was a reluctance to involve more senior staff;Families were locked out of reviews when things went wrong and were often treated without compassion;The trust repeatedly failed to adequately monitor babies’ heart rates, with catastrophic results, and did not use drugs properly during labour;Leaders and midwives were determined to keep caesarean section rates low – consistently 8 per cent to 12 per cent below national averages;There were ‘significant staffing and training gaps’ and ‘medical staff rotas have been overstretched throughout’;One staffer described the department as the ‘Republic of Maternity’ and suggested it did not like being overseen by management.

Katie Wilkins’ baby daughter Maddison died at the Royal Shrewsbury Hospital after busy midwives left her in a side room for 48 hours and failed to monitor her properly.

Miss Wilkins was 15 days overdue when she arrived to be induced in February 2013.

But there were no beds available on the labour ward and instead, Miss Wilkins claims, she was ‘forgotten’ in a side room for more than two days and visited by staff just a handful of times. When a midwife did come to check, they realised her baby’s heartbeat could not be found.

Even then midwife Heather Lort failed to call a doctor and instead told Miss Wilkins to ‘go for a walk’.

Maddison was delivered stillborn the following day, weighing 6lb 14oz. Lort is one of just two midwives found guilty of misconduct and banned from practising. 

Last night Miss Wilkins, 26, a carer from Newtown in Powys, said: ‘Hopefully, the Ockenden report will be the first step towards getting justice for Maddison. The hospital admitted they failed us.’

In a letter to Miss Wilkins, Cathy Smith, head of midwifery at the hospital, apologised and admitted: ‘Had your induction occurred more timely, Maddison would likely have been born alive.’ 

 Katie Anson’s son Kye died after just four days of life due to failures at the scandal-hit trust.

The baby was starved of oxygen in birth at Princess Royal Hospital, Telford, in 2015, but a coroner later heard he may have lived if staff had acted differently.

Miss Anson, 39, and partner Matthew Hall, 34, from the town, were unable to have another child due to unexplained infertility.

Kye died at New Cross Hospital in Wolverhampton. A 2016 inquest heard some heart rate recordings of the unborn baby had not been taken.

Shrewsbury coroner John Ellery said his death ‘could have been prevented’. The couple struggled to get pregnant for two years before Kye. They have just had their sixth failed attempt at IVF. 

Ms Anson said: ‘To have had our only child taken away from us so tragically… makes it all the more difficult to swallow.’ 

Mr Javid last night ordered hospitals to involve mothers in decisions about labour, adding: ‘The only normal birth is a safe birth.’ 

He has apologised to the families who had suffered ‘unimaginable trauma’ and said the Government accepted the report’s findings in full.  

‘It is right that both the RCOG and the RCM have said recently that they regret their campaign for so-called ‘normal births’,’ Mr Javid added.

‘It is vital that across maternity services we focus on safe and personalised care where the voice of the mother is heard throughout.’

Mr Hunt admitted its findings ‘go beyond my darkest fears’.

West Mercia Police, the force carrying out a probe into cases of poor care and deaths at the trust, said no arrests have yet been made but that it would examine whether a criminal case could be brought against either the trust or individuals involved. 

Previous reports into maternity services in Shrewsbury either gave a glowing picture of safe care or called for improvements that were never made.

The chief executive of the trust said that she was confident its services were now safe for families.

Louise Barnett said the organisation was getting the support it needed to make further improvements, adding: ‘I would like to apologise fully to the families involved for the poor care at this trust.’ 

‘We have a duty to ensure that the care we provide is safe, effective, high quality, and delivered always with the needs and choices of women and families at its heart.’

She added the trust had already implemented some of the changes from an earlier report from Ms Ockenden’s team and it will continue to make improvements.

The trust has already paid out more than £58million in clinical negligence damages and costs since 2000. 

Detective Chief Superintendent Damian Barratt, of West Mercia Police, said the investigation into the deaths at Shrewsbury was ongoing.

‘No arrests have been made and no charges have been brought, however we are engaging with the Crown Prosecution Service as our inquiries continue,’ he said.

‘We will be fully reviewing the findings of the report and feeding appropriate elements into our investigation.’

Shrewsbury and Telford Hospital NHS Trust is not alone in having its maternity services scrutinised, with reports expected from both Nottingham and East Kent.

An independent thematic review of maternity incidents, complaints and concerns is currently under way at Nottingham University Hospitals (NUH).

The review, looking at data from 2006, when the trust was formed, until mid October 2021, has been initiated for several reasons, but mainly due to families raising concerns about their cases, according to the review’s website. It is expected to be completed by November 2022.

Meanwhile, an independent review into maternity and neonatal services at East Kent Hospitals University NHS Foundation Trust in the period since 2009 is also under way. 

Last year East Kent Hospitals University NHS Foundation Trust was fined £733,000 over serious failures that led to the death of baby Harry Richford.

At the inquest into Harry’s death in January 2020, coroner Christopher Sutton-Mattocks listed a series of errors he found with the care given.

He gave a narrative conclusion that Harry’s death was contributed to by neglect and had been ‘wholly avoidable’. 

A number of families whose lives and those of their children have been impacted by alleged poor care at Shrewsbury and Telford Hospital NHS Trust are considering legal action.

One of these is the Reverend Charlotte Cheshire, 44, from Newport, Shropshire. 

Her son Adam looked unwell after his birth in 2011, but her concerns were dismissed by staff at the trust, she alleges. 

After it was finally discovered that he had Group B Strep infection, he spent almost a month in intensive care.

Adam, now 11, has been left with multiple health problems. 

She said: ‘What I’m ultimately hoping is that all of the families get some answers.’

‘And then, in our individual cases, about how it’s possible for there to be such systemic failings over so many years, with seemingly either no-one noticing them, or potentially them being covered up.

‘So I’m hoping first of all for answers, but secondly, I’m hoping, as a result of Ockenden, there are genuine learnings.

‘Not the sort of, ‘oh, we’ll learn and get back to you’, but genuine learnings to improve maternity safety – primarily first of all at Shrewsbury and Telford, but secondly across the country as a whole.

‘I don’t want any other family to have to go through what we’ve gone through.’ 

Reverand Cheshire added she was aware some might describe her a lucky as her son lived when so many others did not.  

‘But in a different way it’s changed my life forever, and it’s changed his – because he is hearing-impaired, visually impaired… and has violent, challenging behaviour,’ she said. 

‘Although he turned 11 on Friday, mentally he’s about four. The odds of that changing to a significant degree are highly unlikely. 

‘When he’s happy, when he’s calm, he’s gorgeous, he’s a delight and he’s wonderful, and all of the things you’d expect a mother to say. 

‘But when he’s overwhelmed, I wear the bruises.’ 

Julie Rowlings, whose daughter Olivia died after 23 hours of labour following a consultant’s use of forceps, said she wanted somebody from the trust to talk to her face to face about her case. 

‘I would like somebody from the trust to sit face to face with me, and talk to me. They’ve never done that,’ she said.  

‘They’ve apologised, via media, they’ve apologised to all the families via media, but they’ve never sat down with the families.

‘I want them to apologise face to face for what they put us through.

‘I’d like them to apologise for ignoring what we were trying to tell them at the time. It would go a long way.’

She added that with report’s publication she felt her daughter ‘finally had a voice’, adding that justice for the babies who died was coming.    

‘For every family out there, every family that’s come forward, this is for them.

‘Justice is coming. For every baby, justice is coming.’ 

Previous guidance for maternity staff encouraging women to deliver their babies ‘naturally’ and reduce the rate of C-sections.

In 2007, the RCM, the National Childbirth Trust and the Royal College of Obstetricians and Gynaecologists, signed a ‘normal birth consensus statement’.   

They said: ‘With appropriate care and support the majority of healthy women can give birth with a minimum of medical procedures…

‘Procedures used during labour which are known to increase the likelihood of medical interventions should be avoided where possible.’ 

Two years later, in 2017, the RCM dropped its ‘normal birth’ campaign and removed advice for midwives from its website.

The RCM removed its ‘top 10 tips for a normal birth’ and said the campaign would be dropped in favour of a better births plan.

For its part, the RCOG has recently apologised on Twitter for signing up to the ‘normal birth consensus statement’ in 2007.

It said this ‘may have mistakenly given the impression that targets around childbirth could take priority over safety. This is something we acknowledge and sincerely regret’. 

Shrewsbury and Telford Hospital NHS Trust serves nearly half a million people in Shropshire and consists of two hospitals, the Royal Shrewsbury and the Princess Royal in Telford, as well as a number of smaller community hospitals and maternity units.

Yesterday RCM chief executive Gill Walton said the profession owed a debt to the families who campaigned for the inquiry that she feared ‘can never be repaid’. 

‘What we can do – all of us who are involved in maternity services – is work together to ensure we listen, and we learn from this and ensure that women and families have trust in their care,’ she said.

‘I am asking midwives, maternity support workers, obstetricians and anyone working in maternity services to look around them and ask themselves is the care being provided where you work safe? 

‘If it’s not, I need you to have the courage to speak up, raise your voice and stand up for higher standards. 

‘Poor working cultures lead to a lack of timely and appropriate escalation, which in turn compromises safety. This has to stop.’

Nursing and Midwifery Council chief executive Andrea Sutcliffe also welcomed the report’s findings, saying each case was tragedy. 

‘My heart goes out to all the women, babies and families whose lives have been so terribly impacted by these shocking failings in care,’ she said.

She said the NMC would continue to consider any referrals regarding midwives’ appropriately.

The little girl whose deadly infection was ignored by midwives… just one of the hundreds of heart-breaking tragedies from the NHS maternity scandal that saw 201 babies and nine mothers lose their lives 

Devastated parents who lost children during the NHS’s worst ever maternity scandal have shared heartbreaking stories of the scandal at Shrewsbury and Telford Hospital NHS Trust that turned their lives upside down.

Mothers and fathers revealed how their sons and daughters were stillborn, left with skull fractures or brain injuries due to the incompetence of staff at the sites in Shropshire.

It comes as an independent inquiry into the scandal found some 201 babies and nine mothers could have – or would have – survived if they were provided with better care.

It presided over catastrophic failings for 20 years – and did not learn from its own inadequate investigations – which led to families leaving the hospitals without their newborn babies.

Some 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.

Meanwhile several mothers were made to have natural births despite the fact they should have been offered a Caesarean. Here, the parents tell of their traumatic experiences:

Midwives’ missed chances to save baby Pippa from deadly infection:

Pippa Griffiths could still be alive today had midwives realised she was suffering a deadly infection. The little girl was born at home in Shropshire in April 2016, but died just 31 hours later from a Group B Streptococcus infection.

A coroner ruled her death was avoidable and blamed a string of unforgivable errors by midwives.

The inquest heard medical staff missed a crucial opportunity to save Pippa when her mother Kayleigh rang a midwife with concerns about her baby’s feeding.

A second chance to save Pippa’s life was missed when her mother rang hours later to report bloody mucus, a sign of a serious bacterial infection which could have been treated with urgent hospital treatment.

Pippa was born at 8.34am and a midwife was supposed to have gone to the family home for a check-up later in the afternoon.

But the inquest heard she failed to turn up. Pippa developed a purple rash later that night and eventually stopped breathing. Emergency services managed to get her breathing again, but she later died.

The trust accepted that chances to save Pippa’s life were missed. Following the conclusion of the inquest, Mrs Griffiths said: ‘We’ve fought for her and fought for the truth and ultimately she could have been saved.’

Mother said she’d lost fluid but was told she’d probably wet the bed… but had a stillbirth

Charlotte Jackson raised concerns with staff that she had lost fluid and her baby’s movement had reduced when she was 37 weeks pregnant.

Workers told her she had likely just wet herself, but he son – Jacob Harris – was was stillborn in November 2018 at Telford hospital.

The then 29-year-old from Bridgnorth got lawyers involved and the hospital trust admitted liability and agreed a settlement.

She told the Shropshire Star: ‘I was quite worried and upset. Jacob had always been a very active baby so when I noticed that his movements were reduced I had a gut feeling that something was not right.

‘However, I was shocked when I was told that it was a one off and I’d probably wet the bed.’

She later added: ‘Giving birth to Jacob was absolutely horrific. It’s almost impossible to put into words the emotion of it all, knowing your baby had already died.’

 Reverend said her son looked unwell after being born – but was dismissed by staff:

The Rev Charlotte Cheshire, 44, from Newport, Shropshire, said her son Adam, now 11, looked unwell after his birth in 2011 but her concerns were dismissed by staff at the trust.

When it was finally discovered he had Group B Strep infection, he was rushed to intensive care where he stayed for almost a month.

Ms Cheshire, who is suing the trust, said her son has been left with multiple, severe health problems and should have received treatment much earlier.

She said: ‘What I’m ultimately hoping is that all of the families get some answers.

‘And then, in our individual cases, about how it’s possible for there to be such systemic failings over so many years, with seemingly either no-one noticing them, or potentially them being covered up.

‘So I’m hoping first of all for answers, but secondly, I’m hoping, as a result of Ockenden, there are genuine learnings.

‘Not the sort of, ‘oh, we’ll learn and get back to you’, but genuine learnings to improve maternity safety – primarily first of all at Shrewsbury and Telford, but secondly across the country as a whole.’

She added: ‘I don’t want any other family to have to go through what we’ve gone through.’

Baby boy died 11 hours after being trapped in birth canal for FOUR MINUTES:

Jack Stephen Burn died 11 hours after being trapped in the birth canal for four minutes.

His mother Hayley Matthews had been told nothing was wrong with her pregnancy but later found out Jack had been distressed for 20 minutes before delivery.

He had also contracted group B streptococcus, the lethal infection carried by one in five women.

Jack died in March 2015 at the Princess Royal Hospital in Telford, hours after another baby, Oliver Smale, died following similar complications. Oliver’s death was later deemed avoidable.

Although Jack’s death was not deemed avoidable, it was later considered part of the investigation.

Miss Matthews, from Chirbury, west Shropshire, previously said: ‘We would have both been in the hospital at the same time and there are so many parallels between the two cases.

‘As with this poor boy, Jack got his shoulder stuck during delivery.

‘They just left his head hanging while they went off to get someone to do something about it.’

A post mortem examination revealed that Jack had been starved of oxygen and had an infection on the lung and pneumonia caused by strep B.

Miss Matthews is campaigning for routine screening of strep B, which is not NHS policy. She said: ‘If I’d have been tested for strep B during my pregnancy they might have picked up on it and given me antibiotics at an earlier stage and this means that Jack might still be alive today.’

Staff ignored mother’s warnings and said she was ‘low-risk’ despite daughter being born ‘pale and floppy’:

Kate Stanton-Davies died six hours after she was born because midwives failed to spot tell-tale signs of her deteriorating health.

Her mother Rhiannon Davies had raised fears over reduced movement in the womb, but was ignored by midwives who failed to properly monitor her pregnancy and wrongly deemed it low-risk.

Kate, who had anaemia, was born pale and floppy at Ludlow Community Hospital in Shropshire in March 2009. She was airlifted to Birmingham’s Heartlands Hospital but died.

A report published in February 2016 concluded her death was avoidable and identified a litany of failings and shoddy record-keeping at the Shrewsbury and Telford trust.

Two midwives were deemed responsible for the errors, which included changing Kate’s observation notes after her death.

Mrs Davies said: ‘You would think losing Kate would be the worst event in my life but the continual need to revisit the trauma of that day as we fight to get the truth means my distress is ongoing.

‘How many other baby deaths were avoidable, how many other investigations were not fit for purpose, how many other families have been betrayed, and how many other opportunities for learning have been lost?’

‘My girl was still born after I was left in a side room’:

Katie Wilkins’ baby girl died at Shrewsbury Hospital after midwives left her in a side room for 48 hours and failed to properly monitor her.

Miss Wilkins was 15 days overdue when she arrived at the hospital to be induced in February 2013.

There were no beds available on the busy labour ward and Miss Wilkins, 24, claims she was ‘forgotten’ in the room for two days and visited by staff just a handful of times.

When a midwife did come to check on her progress they realised her baby’s heartbeat could not be found. Maddie was delivered stillborn in the early hours of the following day.

Hospital bosses later admitted the baby would have been born alive had they treated her in a more ‘timely’ manner.

Miss Wilkins said: ‘Maddie’s death was recorded as unexplained but we know why she died – because the midwives didn’t do their jobs properly.

‘I’d had a perfectly normal pregnancy and didn’t expect any problems with the birth. But I was left for hours at a time. The hospital was very busy and I felt like they simply forgot about me.

‘Giving birth to my stillborn daughter was heartbreaking. I should have been taking her home with me, but instead she had to stay at the hospital in a Moses basket. It was awful.’

Maddie was delivered stillborn in the early hours of February 21. The results of a post-mortem examination said the 6lbs 14oz baby girl’s death was unexplained.

In a letter to Miss Wilkins, Cathy Smith, head of midwifery at the hospital, apologised and admitted: ‘Had your induction occurred more timely, Maddison would likely to have been born alive.’ She added that practices at the hospital had now changed.

Miss Wilkins – who has since had a son and daughter with her partner Dave Jackson, 45, – is sceptical. She said: ‘We were told that changes would be made and women would be properly monitored, but now it seems that never happened. The hospital think they can say sorry and we should move on, but we can’t.’

Staff told her she was not suffering an abruption despite severe pains… when she was

Steph Hotchkiss from Telford started to suffer severe pains in September 2014 when she was nearly 31 weeks pregnant and asked if she was having an abruption.

Staff told her she was not, but they were wrong and baby Sophiya passed away just 32 hours later. Steph told the Shropshire Star she still suffers flashbacks of the trauma, caused by a ruptured placenta.

The then 28-year-old had similar issues when her son Kyan was born in 2013, and then had an emergency caesarian.

But she said staff refused to listen to her during her daughter’s birth, with her having told Royal Shrewsbury Hospital staff what she thought was happening.

She said: ‘I can’t put into words how painful this is for us. It was just so frustrating not to be listened to when I had previously had a difficult pregnancy involving a similar thing.’

Encouraged to give birth naturally before baby got stuck and had to have emergency caesarean

Kamaljit Uppal was on the way to having her third child in 2003 but was told it would have to be delivered by caesarean because of how he was lying.

But staff at the Royal Shrewsbury Hospital encouraged her to give birth naturally and she went through 18 hours of labour.

The baby got stuck and Kamaljit had to have an emergency caesarean. She said: ‘I’m still coming out of my general anaesthetic and she said ‘he’s died’ and that’s it. They plonked the baby in my arms and said say goodbye.

‘I didn’t know how to say goodbye, I gave him a kiss and that was it. Once I came around a bit more they put me in a ward where there were babies.’    

Lost one of her twins during labour:

Debbie Greenaway lost one of her twin babies during labour at the trust and said the report ‘doesn’t change what’s happened for 20 years’.

She told This Morning: ‘To begin with, we thought it was just us, we had no idea until they started the report that exactly the same story has happened to so many people.

‘There were so many similarities… I wanted to tell my story and raise that awareness and give women a voice.’

‘Consultants came and went, there was no communication, I didn’t know what drugs I was being given or why, one consultant – I learnt afterwards was trying to take a foetal blood sample from John – which basically they cut his head to find his oxygen level, but they never explained what they were doing. I thought she was delivering them…

‘[At the start of my pregnancy] a c-section delivery was straight away brushed off with ‘we have the lowest caesarean rate in the country, we’re proud of it, there’s no reason for you not to have a natural birth’…’

She had an emergency caesarean, with Debbie saying, ‘When I woke up, all I remember was my husband handing me Daniel, I went, ‘Where’s John?’ and again, another doctor I’d never seen before said, ‘There’s nothing we can do, we need to turn the life support off’… and before I could react to that he walked off and came back carrying John.

‘And in my just come round state, I thought ‘Oh I got that wrong, he’s here, he’s fine’ and when he was handed to me I actually thought he was alive.’

Following a post mortem, she said: ‘All of the time frame was between me going in with two healthy babies with absolutely no issues and an awful long time from when he was brain damaged to delivery…’ 

We lost our only child at 4 days

Katie Anson’s son Kye died after just four days of life due to failures at the scandal-hit trust.

The baby was starved of oxygen in birth at Princess Royal Hospital, Telford, in 2015, but a coroner later heard he may have lived if staff had acted differently.

Miss Anson, 39, and partner Matthew Hall, 34, from the town, were unable to have another child due to unexplained infertility.

Kye died at New Cross Hospital in Wolverhampton. A 2016 inquest heard some heart rate recordings of the unborn baby had not been taken.

Shrewsbury coroner John Ellery said his death ‘could have been prevented’. The couple struggled to get pregnant for two years before Kye. They have just had their sixth failed attempt at IVF.

Miss Anson said: ‘To have had our only child taken away from us so tragically… makes it all the more difficult to swallow.’  

SARAH VINE: At the heart of this maternity care tragedy is an extreme ideology that has turned motherhood into a toxic battleground

Can you imagine a forceps delivery so violent it shatters a baby’s skull? Or a woman in the agonies of labour being told she’s ‘pathetic’ and ‘lazy’? 

Or relatives of a deceased mother being told that it was partly that mother’s fault ‘because she clearly did not complain very much’? 

Sounds like something out of the Dark Ages, does it not?

And yet this is the state of maternity care in modern 21st century Britain. And it is nothing short of shameful.

The inquiry into the deaths of mothers and babies at the Shrewsbury and Telford Hospital NHS Trust, published yesterday, has unearthed a catalogue of horrors almost too gruesome to contemplate. 

Over 200 babies and nine mothers dead, 94 children brain damaged as a result of neglect, incompetence and, in many cases, what can only be described as an astonishing level of malice on the part of the medical practitioners.

Their job was to care for these pregnant women. But instead – as we read from accounts of witnesses – they seemed to take an almost perverse delight in making them suffer. And that may well be just the tip of the iceberg: 600 cases involving the Shrewsbury Trust are currently being investigated by the police.

One grieving parent, Richard Stanton, whose daughter Kate died soon after being born in 2009, expressed the hope that the report would result in prosecutions. Donna Ockenden, the senior midwife in charge of the inquiry, which took five years to complete, has said she feels ‘ashamed’ of what went on.

‘We have seen families that have been split apart, families where relationships have been broken, cases of trauma and PTSD that have persisted for years after the event as well as terrible, terrible sadness. At times, after meeting families, I went back to my hotel room and I cried,’ she said.

Such a catastrophic failure, on such a scale, is hard to understand. It seems impossible that someone, somewhere, would not have noticed what was going on, that a situation so clearly appalling could have been allowed to persist for so long without some authority stepping in or asking questions.

In truth, though, to mothers everywhere, a lot of the behaviour and attitudes that have transpired from this report will feel depressingly familiar.

At the heart of this scandal lies an extreme ideology that has turned motherhood into a toxic political battleground. A rigid dogma that resulted in disastrous misjudgements which, ultimately, cost the lives of innocent women and children.

I’m talking about the NHS’s obsession – central to this report on Shrewsbury and universally acknowledged as a major factor – with so-called ‘natural’ childbirth, almost at any cost. An aversion to the idea of medical intervention during labour and a particular horror of caesarean sections.

One that, in my experience and in the experience of many women I’ve spoken to over the years about this, is shared across all maternity services, and especially in the midwife community.

Of course there have always been a number of natural-childbirth advocates around. But around the end of the Nineties the movement gained momentum, and the notion of ‘good’ and ‘bad’ childbirth really seemed to take hold.

And the truth is, the NHS – run by managers, as it is, rather than doctors – had every incentive to encourage it.

A caesarean section generally costs considerably more than a ‘natural’ birth. Bodies such as the Royal College of Midwives (RCM) and Royal College of Obstetricians and Gynaecologists (RCOG) made it clear that they were not in favour of medical intervention during childbirth. Mother Nature knows best was the mantra – even though, of course, maternal death rates before modern medicine would strongly suggest otherwise.

Nevertheless, childbirth became less of a clinical issue and more of a moral one. Women who were unable to give birth naturally were suddenly seen as cowards and failures, ‘too posh to push’, somehow inadequate for going against the natural order of things.

Even asking for pain relief was considered a cop-out. Breathing exercises, we were told, was all ‘real’ women needed. There was an awful lot of baloney bandied about about how ‘empowering’ vaginal delivery was, how it would flood your body with magical hormones, and make you feel like the ultimate ‘feminine goddess’.

This in turn fed into the obsession with breastfeeding, and the instant chastisement of any mother who ever eyed up a tub of Aptamil formula milk in the supermarket.

When I had my first child in 2003, I clearly remember such attitudes prevailing. At my NCT antenatal classes at the local hospital, instructed by midwives, the first thing we were told was that a vaginal birth – described as ‘normal’, the clear implication being that anything else was ‘abnormal’ – was the ‘desirable’ outcome.

We were shown endless slides of Native American women squatting in forests (I kid you not), and told that epidurals would ‘numb’ the beautiful experience of childbirth (when I put my hand up and pointed out that I thought numbing was the whole point of them, I was met with a very stern stare). 

Caesareans were the devil’s work, a measure of last resort, and entirely avoidable provided we, as mothers, trusted in our midwives. Ah, trust in the midwife. I did that, and it almost ended in disaster.

When I eventually went into labour with my first, I did exactly as I was told. I waited until my contractions were however many minutes apart they should have been (I can’t honestly remember now), and then I went to hospital. When I got there, I was examined, told my labour was progressing nicely, and given a room.

A few hours in, and something clearly wasn’t quite right. I was examined again and told that my labour had stalled. I was given drugs to speed up the process, and then began an agonising night. By the time the obstetrician came to do her rounds the following morning, I had progressed to no further than 4cm dilation (you need 10cm), was struggling to breathe – and my daughter was in distress.

The obstetrician took one look, said something furiously under her breath to the attending midwife (one of several that came and went) and rushed me to the theatre. After a day and a half in labour, I underwent an emergency caesarean, and my daughter was born safely.

At every turn the midwives made me feel stupid, lazy and inadequate for not ‘progressing’ with my labour. All they seemed to care about was making sure I did things their way. And yet their way was not exactly exemplary.

My daughter was posterior presented, meaning she was face up in the birth canal instead of face down – a position that makes it very hard for the cervix to dilate sufficiently to allow a vaginal birth. 

But not one of the midwives present had identified this. Had they done so, it might have been possible to turn her. But such was their incompetence – or neglect – that by the time the problem had been identified, it was too late. She had to come out, fast.

Had I been left in their hands – or had the hospital had a no caesarian policy – who knows what would have happened. Maybe they would have tried to remove her with forceps; maybe she would have been brain damaged, like so many of the poor babies in this case. I consider both of us very lucky.

There are many lessons that must be learned from the appalling failures at Shrewsbury. Some of the families affected have been financially compensated. They will no doubt still seek proper justice, and rightly so.

But if any good is to come out of this tragedy, surely it must be a change in attitudes towards childbirth. As well as an acknowledgement on the part of the medical professionals involved that no mother, or baby, should ever be a pawn in the political games of others.