BBC Panorama looks at Shropshire’s scandal hit maternity service

In a programme to be shown tonight, BBC Panorama spoke exclusively to the former consultant gynaecologist who spent almost 30 years at the Shrewsbury and Telford Hospital NHS Trust (SaTH) before retiring in 2020.    

The Trust is at the centre of the largest inquiry in the history of the NHS into maternity care, which is expected to report next month. An official investigation is examining the care that 1,862 families received at the Trust.  Over twenty years, babies that should have been born healthy suffered permanent harm or died due to poor maternity care. 

Speaking publicly for the first time, Bernie Bentick says he told senior management several times about a deteriorating culture at the Trust: “I was increasingly concerned about the level of bullying, of dysfunctional culture, of the imposition of changes in clinical practice that many clinicians felt was unsafe… If the resources had been made available to employ adequate numbers, to provide safe levels of care in accordance with national guidelines, then the situation may have been profoundly different.” Mr Bentick went on to say that though some “cursory” investigations were launched into his complaints he believed the Trust responded in a way that tried to “preserve the reputation of the organisation…”  

Fighting for the Truth

In Maternity Scandal: Fighting for the Truth BBC Panorama has discovered that the scandal-hit maternity unit was praised by MPs in a Parliamentary Hearing in March 2003 for its low caesarean rate. In an evidence session seen by Panorama, the clinical director of the Royal Shrewsbury at the time told MPs: “The culture of our organisation is that we have low intervention rates and once that is known we attract both midwives and obstetricians who like to practise in that way.” 

In the same session the manager of women’s services at the time said: “When I interview midwives who have not trained in Shropshire… some of them have never seen a baby born in breech…delivered vaginally. They almost need retraining to be able to work in Shropshire.” 

But it is now thought that these low caesarean rates could have contributed to poor outcomes. 

In an interim report into the Trust published in 2020, Donna Ockenden, the head of the inquiry into the Trust and a senior midwife, noted that caesarean rates at the Shrewsbury and Telford Trust were between 8-12% lower than the England average. Speaking exclusively to Panorama, she said the Trust had been lauded for its low caesarean rates. “There were cases where an earlier recourse to caesarean section rather than a persistence towards a normal delivery may well have led to a better outcome for mother or baby or both. Low caesarean section rates were a prize.” 

Last week, NHS England asked all maternity services to stop using caesarean section rates to measure performance. 

VIDEO: Donna Ockenden speaking to Michael Buchanan on BBC Panorama to be shown tonight on BBC ONE.

Families who were failed

Panorama hears from families who were failed by the Trust. Just a month after the parliamentary hearing, Kamaljit Uppal went into the Royal Shrewsbury hospital in April 2003 expecting to have a caesarean section as she had been told her son had been in a breech position during her pregnancy. Instead, she was encouraged to deliver naturally and endured an 18-hour labour before medics ordered an emergency caesarean.  But her son, Manpreet, died two hours after he was born. A post-mortem was carried out and Kamaljit and her husband were invited to meet a consultant. She told Panorama, the medic’s conclusion: “…if we'd given him a C- section earlier, he would have lived a normal life.” Mrs Uppal says that the Ockenden review is the first time her son’s death has been properly investigated, a failure that other families have also reported.   

Panorama has discovered that when it examined incidents of poor care, the Trust devised its own investigation system, called a High Risk Case Review (HRCR). The programme understands that the use of HRCRs meant fewer serious incidents were reported to NHS regulators, limiting the opportunity to learn lessons.    

Asked about the programme’s findings, Donna Ockenden said: “It appears to be a locally held investigation process, kept in-house in maternity services.  It’s not something that I have ever seen or heard of in any other maternity service. Clearly if a trust has its own home-spun methodology that is simply not good practice.”  

Ockenden Report

Next month, the full Ockenden report will be published.   

Shrewsbury and Telford Hospital Trust declined to be interviewed for Panorama. In a statement it said: “As a Trust we take full responsibility for the failings in the standards of care within our Maternity services. We offer our sincere apologies for all the distress and hurt we know this caused.” The Trust also said it has made ‘strong progress’ including ‘significant investment in additional staff and staff training’. It said it has completed over 80 per cent of the actions set out in the first Ockenden Report.  

The Trust told Panorama that it had adopted the term ’High Risk Case Review’ for incidents that did not meet the reporting requirements of a Serious Incident report or other ‘external’ reporting requirements. It said it stopped using the term in 2020 and has 'refreshed and aligned' its incident reporting. 

BBC Panorama - Maternity Scandal: Fighting for the Truth can be watched tonight on BBC ONE at 9pm.