Maternity scandal report: ‘normal births’ and how care can change for the better

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Today (30th March 2022), the final report into the maternity scandal at the Shrewsbury and Telford Hospital NHS Trust (SaTH) was published. It follows a five-year independent inquiry led by Donna Ockenden, an expert midwife. It is thought to be the largest review of its kind in NHS history.

It will be an exceptionally difficult day for the families involved in the inquiry, and for those whose lives have been affected by poor maternity care elsewhere. It will also be challenging for midwives and maternity clinicians. We hope that the findings of this report can be navigated with empathy and respect for both the families and for midwives/clinicians who have only ever done what is best for their patients, but most importantly, that everyone involved can listen, learn and accept that improvements can be made in maternity care in the future.

The Ockenden report’s findings about standards of maternity care

The report found that at least 201 babies would have survived with better care, including 131 stillbirths and 70 neonatal deaths. Nine mothers died and 94 children suffered avoidable brain damage. There were 1,592 incidents of poor care over “two decades of repeated failures”.

We knew from the interim report that the investigation would look at:

  • Stillbirths, brain injuries to babies and sometimes baby deaths as a result of failures to monitor babies’ heart rates at all, or monitor them appropriately and identify abnormalities, and escalate concerns
  • Unnecessarily long labours, allegedly to avoid high hospital C-section rates
  • Trauma caused by excessive use of forceps
  • One incident whereby a baby suffered a fatal brain injury as the result of staff being “too busy” to adequately monitor a mother

Donna Ockenden said of the report: “The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the Trust and a culture of not listening to the families involved. There was a tendency of the Trust to blame mothers for their poor outcomes, in some cases even for their own deaths.”

Recommended actions to improve maternity care

The report sets out 15 immediate and essential actions, covering 10 areas, including:

  1. Financing a safe maternity workforce
  2. Essential action on training
  3. Maintaining a clear escalation and mitigation policy when adequate staffing levels are not met
  4. Essential roles for Trust Boards in oversight of their maternity services
  5. Meaningful incident investigations
  6. Mandatory joint learning across all care settings when a mother dies
  7. Care of mothers with complex and multiple pregnancies
  8. Ensuring the recommendations from the 2019 Neonatal Critical Care Review are introduced at pace
  9. Improving postnatal care for the unwell mother
  10. Care of bereaved families

Donna Ockenden suggested the recommendations should be seen as a ‘blueprint’ toward safe maternity care for all.


In 2008, the Royal College of Midwives (RCM) began the campaign for ‘normal’ (vaginal) birth after decades of some healthcare groups advocating for it and pushing for low C-section rates. As this article explains, it was felt that this was the right thing to do to reduce what was seen as an ‘over-medicalisation’ of birth. The RCM published top 10 tips for achieving a normal/natural birth, which included a ‘wait and see’ approach.

In 2017, it was announced there would be guidance for midwives to stop using language that would push women into births without medical intervention as this could put babies at risk, particularly where it made women feel reluctant to ask for help. The Chief Executive of the RCM at the time said it was inappropriate to push any agenda of their own on pregnant women. It was noted that a change in practice was required where a ‘value judgment’ was being placed on women who asked for pain relief or a C-section.

The maternity scandal at SaTH comes on a background of previous scandals, for example, at:

  • London North West University Healthcare NHS Trust: this Trust’s maternity service was investigated twice about the deaths of 10 women between April 2002 and April 2005. The Trust had maintained there were no common factors between the 10 deaths when the seriousness of the situation should have been appreciated and links been identified.In June 2021 the CQC downgraded the Trust’s rating from ‘requires improvement’ to ‘inadequate’. It found poor culture and bullying in the maternity service, and there had been eight baby deaths in a five-week period between July and August 2020.
  • University Hospitals of Morecambe Bay NHS Trust: the Kirkup Report was the outcome of an investigation into events between January 2004 and June 2013 at this Trust. It found that failings in the maternity service led to the deaths of 11 babies and one mother. The report said that the response to potentially fatal incidents was “grossly deficient, with repeated failure to investigate properly and learn lessons”. At Morecambe Bay, there was a group of midwives who would seek a ‘normal’ delivery at any cost and refused to call doctors when needed. In August 2021, the maternity unit was labelled ‘inadequate’ by the CQC.
  • East Kent Hospitals University NHS Foundation Trust: In April 2021, this Trust pleaded guilty to failing to provide safe care after a rare CQC prosecution, the first of its kind. This arose out of the avoidable death of baby Harry Richford.
  • Nottingham University Hospitals NHS Trust: a report found that 46 babies suffered brain damage and 19 were stillborn at Nottingham University Hospitals between 2010 and 2020. It says managers “failed to properly investigate concerns and altered reports to take blame away from the maternity unit”.

Concerns were first raised about SaTH in 2009 when baby Kate Stanton-Davies died six hours after birth. Midwives had ignored her parents’ concerns and failed to realise the pregnancy was high risk. In 2018, when concerns had been raised about SaTH and the Ockenden inquiry had begun, the Trust dismissed claims of further cases being uncovered as “irresponsible and fear mongering”.

With that background in mind, Donna Ockenden said in December 2020 that at SaTH, they had found evidence of a multi-professional focus on normal birth “at pretty much any cost”.

Improving safety and care

Campaigns and investigations do bring about change and improvement. The ONS reported that, in 2020, the stillbirth rate was 3.8 per 1,000 births, the lowest since records began. Campaign for Safer Births, for example, pushes for Coroner involvement in stillbirths (Coroners currently have no power to investigate stillbirth as there is ‘no independent life’, meaning the same scrutiny isn’t applied to stillbirth as an infant death) and provides information to those who have experienced poor care and negligence in childbirth.

In February 2022, a letter from NHS England’s Chief Midwife and National Director for Maternity to NHS maternity units was leaked. It instructed all maternity units to stop using C-section rates for performance management. Given the focus on ‘normal’ birth at SaTH, which had the highest ‘natural’ birth rate in England between 2010-18 (2018 being the year the inquiry began), this can only be a victory for patient-centred care, autonomy and informed consent.

NHS Resolution reported that in the year 2020/21, the total cost of clinical negligence cases was £2,209.3 million (apparently a decrease from the year before). Around 40% of that relates to maternity care cases. This case study explains how a birth injury case can end up being valued at millions of pounds.

Find out more about the importance of clinical negligence claims and why the human cost of clinical negligence outweighs the bill in this blog.

The Early Notification Scheme

With a view to improving patient safety and reducing the cost to the NHS, the Early Notification Scheme was launched in April 2017. The purpose is to investigate and identify where an apology or early admission can be made in these cases, which would reduce the cost of any subsequent clinical negligence cases.

The future of safe maternity care

Before the release of this final report, Gill Walton, the Head of the Royal College of Midwives (RCM) issued an apology for the RCM’s part in promoting ‘normal’ births that contributed to the deaths of mothers and babies. She has today released a statement speaking on the dangers of poor culture and encouraging those to speak out about instances of unsafe care. It is reassuring to see this, alongside her calls for robust training and adequate funding.

There are many contributory factors to what happened at SaTH, and all must be addressed. Maternity units need to be properly staffed and midwives properly supported in their professional environment. They cannot be failed by the system, particularly in a way that means they cannot offer an appropriate standard of care.

Maternity care also needs to be better funded, and we echo the report’s call for proper investment in maternity services so that midwives and doctors are well supported.

It is particularly important that the role the campaign for ‘normal’ births played is not ignored or minimised because, as we have seen after the release of reports into previous maternity scandals, this can prove incredibly harmful.

As medical negligence solicitors we hope that this time, lessons are learned. Patients must be centred in their care and properly informed and supported in terms of making choices about the type of birth they have.


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