LONDON — Dozens of babies and three mothers died at hospitals in England over four decades because of major staff failings, in what experts said could become the biggest maternity scandal in the history of Britain’s National Health Service.
The problems at the facilities that make up the Shrewsbury and Telford Hospital NHS Trust from 1979 to 2017 resulted in dozens of stillbirths as well as the deaths of newborns and women who had just given birth, an independent investigation ordered by the government in 2017 has found. It also cited more than 50 cases of injury.
The findings were summarized in an interim report first disclosed by The Independent and seen by The New York Times. It identifies hundreds of cases of repeated failings and clinical errors by doctors, midwives and hospital bosses, as well as a lack of transparency and honesty.
A senior official at the National Health Service called the findings a major and disturbing scandal. More and more people are coming forward by the day, he said, adding that the problems may well extend beyond the Shrewsbury and Telford Hospital Trust.
In one case at Shrewsbury and Telford, a baby suffered a brain injury at birth because the medical staff monitored the wrong heartbeat and thus missed signs of distress, the report said. In another, the hospital failed to notify a mother that her baby’s body had been returned from a post-mortem examination, and then advised her not to look at the body because it had decomposed during the delay, it said.
The report, written by a midwife, Donna Ockenden, warns that even now hospital staff members have not absorbed the lessons of their past failings.
“The number of cases we are now being requested to review seems to represent a longstanding culture at this trust that is toxic to improvement effort,” the report says. “It will take time, confidence and considerable and meaningful staff effort from ‘Ward to Board’ to change this, and it will require strong leadership and the support and receptiveness of senior managers.”
The Shrewsbury and Telford Hospital Trust said that it had not been made aware of the interim report, but that it had already made improvements to its maternity service.
“On behalf of the trust, I apologize unreservedly to the families who have been affected,” said Paula Clark, the interim chief executive of the Trust.
Ms. Clark said: “I would like to reassure all families using our maternity services that we have not been waiting for Donna Ockenden’s final report before working to improve our services. A lot has already been done to address the issues raised by previous cases.”
The inquiry into the Shrewsbury and Telford Hospital Trust was prompted by a campaign by a couple demanding answers about the death of their first child in 2009. In an interview, the mother, Rhiannon Davies, said the scope of the failings revealed in the report was “horrific” but not surprising.
“Exposing these details has been our reality for the past decade,” she said, “but yet we have been treated like we are guilty of something, whereas the midwives and hospital staff have been treated like the victims.”
Ms. Davies was skeptical about claims that conditions had already improved.
“They keep saying that lessons are being learned, but we keep getting confronted with the same abuses,” she said. “Why should we believe that anything will change now?”
Ms. Davies’s daughter died after midwives at Ludlow Hospital failed to identify signs that the newborn was in critical condition and left her alone in a crib, she said. The child was airlifted to another hospital but died six hours after birth.
The hospital also failed to classify Ms. Davies’ pregnancy as high-risk, even though she had a series of serious medical problems and was in and out of the hospital for two weeks before giving birth, she said.
In their decade-long battle for an investigation into their daughter’s death, Ms. Davies and her husband, Richard Stanton, had to threaten a judicial review of the hospital’s investigation of the death before they were granted an inquest, she said.
In 2013, that investigation by the Parliamentary and Health Service Ombudsman, which examines unresolved complaints against the government and the National Health Service, concluded that the child had died as a result of serious failings in care and that her death could have been avoided.
Today, more than 600 cases of possible malpractice in the maternity wards of the Shrewsbury and Telford Trust are being investigated as more families come forward. The N.H.S. is carrying out a parallel investigation into the Trust. The West Mercia Police, which has jurisdiction over the trust, said it would wait for the findings of the independent inquiry before considering any criminal proceedings.
“I feel like I’ve been pushing this huge boulder that could roll back and crush me at any point,” Ms. Davies said, “and indeed it has, many times. But now maybe, just maybe, it has some momentum and can roll without me.”