"Catastrophic errors" in public maternity wards of a NHS district administration in the west of England cost the lives of more than 200 babies over a period of 20 years, is the final result of an independent study published yesterday.
The findings of midwife Donna Ockenden on behalf of the British government show that the deaths of 201 infants and nine mothers who died in NHS hospitals in Shrewsbury and Telford during the period 2000-2019 could have been avoided
These are 131 babies born stillborn and another 70 who died shortly after birth. In another 94 cases, the infants suffered severe brain problems.
Ms Ockden studied 1.592 suspicious clinical cases involving 1.486 families.
He concluded that in this NHS trust there was a culture that promoted natural childbirth versus caesarean section without always adequately assessing the risk to pregnant women and fetuses.
There was also insufficient monitoring of newborns, but also failure of those in charge to learn from previous mistakes.
"There was not enough staff, there was a lack of continuous training, there was a lack of effective incident investigation and leadership in the trust and a culture of not listening to the concerns of families. "There was a tendency in this regional unit to blame mothers for mistakes, in some cases even deaths," Donna Ockenden added.
Health Minister Sajid Javid apologized to the House of Commons from the House of Commons to all the families who have suffered medical malpractice in the area's hospitals and pledged to implement the findings in all maternity wards in England.