Shropshire baby and mother maternity deaths review widened Published duration 31 August 2018

media caption Jack Burn died hours after being born at Princess Royal Hospital in Telford

An independent review into a series of baby deaths at a hospital is to be expanded after more families came forward with concerns about their care.

In 2017 Jeremy Hunt ordered an investigation into maternity care relating to 23 cases at the Shrewsbury and Telford NHS Trust (SaTH).

This has increased to more than 40, but the trust said these were cases already in the public domain.

The trust said it had worked "openly" with the investigation.

Senior midwife Donna Ockenden was appointed last year to review 23 cases - including baby deaths, maternal deaths and brain injuries - of alleged poor maternity care at the trust.

A spokesperson for NHS Improvement said it had to agreed "to consider additional historical investigations that have been highlighted since our independent review was announced in April 2017, where women, infants and new-born babies had died or suffered harm in the maternity services provided by Shrewsbury and Telford Hospital NHS Trust".

"This includes the cases that the trust had considered as part of its legacy review, as well as the finding of the review it commissioned the Royal College of Obstetricians and Gynaecologists to undertake."

Richard Stanton, 48, whose daughter Kate Stanton-Davies died nine years ago, said: "It doesn't surprise me, it deeply saddens me."

He welcomed the move to bring all the investigations under the umbrella of the Ockenden review, so there could be "consistency" with cases looked at "with the same eye".

"In my view, there's serious questions for the leadership, management, governance and policies at this trust, as it's been a systemic failure."

image copyright Richard Stanton image caption Kate Stanton-Davies, pictured with her mother Rhiannon, was born at Ludlow Community Hospital

Hayley Matthews's son Jack Burn was born in March 2015 but died of hypoxia and Group B Strep within hours.

She said that throughout her 36 hour-long labour at the Princess Royal Hospital in Telford she was refused a caesarean section several times and had a natural birth during which her son's shoulder was trapped.

"It makes you angry, all these parents going through what I went through three years ago. They said changes have been made but at the moment we're failing to see any," she added.

"I was just another number on a bed."

image caption Devan and Gavin Cadwallade believe their daughter's death was preventable

Devan and Gavin Cadwallade's daughter died at the Princess Royal Hospital last December.

Devan had complained to staff that her baby's movements had slowed but she was reassured everything was fine.

After three days in hospital she was told her daughter had no heartbeat.

"I was just a number to them, it was just a bed and no-one stopped to think, 'hang on, this isn't normal,'" said Devan.

A post-mortem failed to find a cause of death and the couple believe it was preventable.

"I think in our heads, although it's horrible to say, if something had been wrong with her we could maybe deal with that a little bit more," said Gavin.

It said in a report that a culture of learning from incidents "was not apparent" and the lack of staff - particularly midwives and consultants - "was a patient safety issue".

While the publication of their report was at the trust's discretion, the process did allow the Royal College to "refer to a regulator in the public interest any matters they consider require this".

Dr Edward Morris, a vice president for the Royal College, said: "The Care Quality Commission had already performed a visit and a detailed review into the trust as a whole and the maternity services.

"The safety and quality of the care they delivered was largely reported as good, true in two hospitals there were areas that required improvement.

"Therefore we felt there was no additional need to present our findings as an acute safety concern."

SaTH said it had reviewed 40 cases, 23 of which had no signs of failure of care and five of which the families could not be contacted.

It said it had also written to 12 other families to seek permission for their care to be reviewed as there "may be potential for further learning".

The trust's chief executive Simon Wright added: "The death of any baby is a terrible ordeal for any family. We take our responsibilities in reviewing these cases very seriously.

"To suggest that there are more cases which have not been revealed when this is simply untrue is irresponsible and scaremongering."

Powys Community Health Council said the issue would be "worrying" for people in the county who used the services.

In a statement it said: "Since concerns were first raised, the Community Health Council has sought assurance from Powys Teaching Health Board that the services they commission for Powys residents are safe."

A Department of Health and Social Care spokesman said: "We take any patient safety concerns extremely seriously - we have asked NHS Improvement to investigate whether further cases at Shrewsbury and Telford should be considered as part of the Ockenden Review, as well as assurance that the trust has taken steps to improve maternity services since these issues came to light in 2016."