Shrewsbury and Telford: how the UK’s biggest maternity scandal unfolded

The findings of an investigation into failures of care at Shrewsbury and Telford Hospital trust’s maternity unit over a period of almost 20 years will be published in the next few weeks.

The cases of 1,862 former patients are being examined in a probe into “one of the biggest scandals in the history of the NHS”, said the BBC’s social affairs correspondent Michael Buchanan.

In an initial report in December, Donna Ockenden, who is leading the review, said families had spoken “about their experiences of pregnancies ending with stillbirth, newborn brain damage and the deaths of both babies and mothers”.

‘Cultural problems’

A former consultant obstetrician and gynaecologist who worked at the trust for almost 30 years has told the BBC’s Panorama programme what he believes contributed to the trust’s failings.

Bernie Bentick, a former consultant obstetrician and gynaecologist at the Shrewsbury and Telford trust, said that he sent emails to the hospital’s senior management on several occasions highlighting “incidents of dysfunctional culture, of bullying, of the imposition of changes in clinical practice that many clinicians felt was unsafe”.

Bentick explained that the unit’s “resources were scarce”, and former employees have also highlighted that a lack of midwives and consultants was a problem for some years, said Buchanan. 

As a result, said Bentick, “there was a tendency to blame individuals for not following guidelines rather than look at the underlying factors which may have led to a particular problem, and in particular staffing levels in the midwifery department.”

Though “cursory” investigations were launched in response to Bentick’s complaints, he does not believe that hospital management “really understood the gravity of the cultural problems within the trust”.

‘Unorthodox’ case reviews system

The trust also had a “culture of having low rates of Caesarean sections”, the BBC’s Buchanan told Radio 4’s Today programme this morning. At one point, the hospital was performing the lowest number of C-sections in England, and although there was at the time a national drive to reduce the number of these being performed, Buchanan said it appears the trust applied that guidance “too vigorously”. 

One reason the failings in care went on for so long also appears to have been that NHS regulators weren’t necessarily aware of the incidents and patients’ complaints. An interim report published in December 2020 has highlighted that “in many cases the trust failed to investigate after something went wrong, or simply carried out its own inquiry”, said Buchanan. 

Panorama also revealed that the trust “developed its own investigation system, what they called a High Risk Case Review”. This “unorthodox” system doesn’t seem to have been used “in any other NHS organisation”, said Buchanan. It resulted in fewer incidents being reported to NHS regulators, thereby “limiting the opportunity to learn lessons”. 


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