201 babies and 9 women died, 94 babies with life changing injuries, all avoidable

[Lovelyricepudding]

At one hospital. Who knows about other hospitals? A system set up for internal investigation that looked like it may have been designed to avoid external involvement.

This is the state of maternity care in the UK.

Horrific, and utterly heartbreaking.

I'm another who's not surprised though based on personal experience.

There needs to be better dialogue all round, a vaginal birth can be a positive experience and whilst it wasn't jumping bunnies, none of mine were negative (in the bigger picture) experiences.

There was some issues - being told that I couldn't possibly be ready to push because it hadn't been long enough, and they reluctantly agreed to examine me - yes I was fully dilated. With number 2, I was slightly pre-term so was continually monitored and still told that I wasn't in labour. Thankfully the mw on the prenatal ward picked up that I was and so kept a close eye on me. The 'problem' I had and indeed my mom did too was that we labour in our hips so the machine does not pick up contractions - in fact the told my Dad to tell her to stop moaning - my sister was born 30 minutes later (bear in mine this was also a high risk pregnancy following a still birth) The first time I was stitched without any pain relief.

There is a common theme though, not being listened too, I was even told when my waters broke with dc2 that I had simply wet myself - my waters had gone at the onset of labour with dc1, I knew what I was feeling, but no it was simply that I had wet myself. dc1 they tried to send me home because they were so certain I wasn't in labour.

I watched the Panorama programme and in many of the stories there was nuggets of my experiences, I don't know why I was listened to and they weren't, being told it wasn't their waters that had broken, or that they couldn't possibly be in labour.

I shouldn't just be one of the lucky ones who had good experiences and good outcomes,* this should be for everyone. For some this will be a CS for others a VB on a few puffs of gas and air.

*Bar my earlier recounted experience, the experience and calmness of that MW potentially prevented a different outcome.

33 hour active labour with my first. No real desire for natural or otherwise labour. Slightly worried about a c section only because my husband had only passed his driving test literally days before but figured we'd manage if it came to it. My basic philosophy was I'd take the drugs if needed and get the baby out however possible.

Drugs never offered and because I didn't ask they assumed I was fine. I wasn't allowed to push for two hours after getting to 10cm due to previous lung issues. Later found out that standard protocol for this is to give an epidural as it's nearly impossible not to push when fully dilated. Consultant at different trust for second baby when I recounted this was horrified and wanted names. I was exhausted before I even got to pushing.

Consultant said I'd need a c section about 4 hours before it actually happened. Once he left the room midwife dismissed what he said and insisted I WOULD be doing it naturally

Baby's heartbeat lost several times. By the time midwife admitted defeat we didn't know if our baby was going f to be alive when they got him out. Thankfully he was but he was incredibly poorly and straight to NICU. Didn't get to see him for 24 hours. Told the second day that he might not make it. Somehow he did.

My second baby was an elective c section. Fuck natural birth at any cost. This philosophy has to stop. It's a wonderful thing but not at the expense of anyones health or survival

My DD had GBS sepsis at birth last year, which affected so many of the babies in this report. She survived with (so far) no long term complications identified due to the brilliant team at our hospital who picked it up early and got her into the NICU in good time. I'm so so angry that others in the UK haven't been able to access the same level of care and i just feel so much for all the women affected in the report. The two mothers who pushed for this are absolutely amazing.

I heard Rhiannon being interviewed on Today this morning. What an extraordinary woman. She has turned her tragedy into an expose of a horrific culture. That Times article is sickening. I look at the photos if those men who presided over the regime and I want them to feel just a scintilla of the psi they put those women through.

@Gingernaut

The bravery of the two mothers who initiated the investigation cannot be underestimated.

Eight seperate bodies were involved in inspecting care at the trust and all found nothing to be concerned about.

It is only thanks to Rhiannon Davies and Kayleigh Griffiths that this investigation was ever instigated.

Amazing women. Lots of mothers and babies will be saved due to them. 💐

It's just so tragic and sickening. This is my local trust and it's affected one of my close friends personally, so to see her go through all that she has and then see the findings is just harrowing. It's rocked the local community too for years since the investigation first started. I had maternity care in Shrewsbury back in 2000 and I remember them saying then there were not enough midwives. It's the story in so many other places though, I had terrible substandard care in another trust that left me with PTSD and my baby damaged.

@Wintersbone

It doesn't surprise me one bit. NHS maternity care in some places is worse than most developing nations. They fiddle the data to make it look ok but it's reallllly not. If we couldn't have afforded private I wouldn't have had any more children. I have life changing injuries. And no one cares. Most women don't even bother to complain because there's so little point. The two women who instigated this should be made heros.

💐💐💐 all I can give you.

We go trusting nhs and then

They treat us like we are children and we trust them as we don’t give birth often so we don’t know.
Then they lie to us and cover it up

Thank you to all who exposed this

I've said this on some of the other threads but I saw a brilliant (female) consultant with my second pregnancy who was great at offering ELCS and helping me decide whether that was a good choice for me.

I had to speak to the most offensively clueless male doctor (? I assume he had some medical training as he appeared to be employed to give medical advice but if you'd told me it was a practical joke I'd believe you) before I spoke to her - but thought I'd mention the first to show that it can be done!

Rhiannon and Kayleigh - thanks for speaking out and fighting for all pregnant women and their babies 💐

So awful to read.

The drumbeat of this report is the failure again and again and again to investigate properly when things went wrong, decide what to do about it in the best ways, and then to actually DO any of the action plan. Effort expended mainly to keep investigation local and less exposed.

I would actually like a companion report on Trusts that are good at maternity services. There must be some. Not isolated ideas or schemes but good care, good culture, good clinical governance, over a period of time.

I wonder if some of those Trusts would have relatively poor ratings on postnatal care, which we all know can be awful, and allow partners to stay even if it means less than ideal circumstances for women finding there are men overnight on the ward, because they prioritise having staff on the delivery unit where the lifethreatening stuff happens. There might be tradeoffs. At least this report actually mentions more money.

YY to pp who have said that at the time, the culture was natural birth at all costs. I remember being asked 'But didn't you feel you'd failed?' because I'd had gas & air to help deliver the placenta. I'd given birth to my daughter on the bathroom floor, in an unplanned home birth, and she'd had the cord wrapped so tightly round her neck that she was blue and needed resuscitating by the paramedics.

It has been heartbreaking listening to the testimony of so many women saying 'I knew something was wrong, but no one listened to me'. Childbirth is when we are at our most vulnerable, so for the trust to have what seems to be such a callous attitude is genuinely horrifying. I am in awe of the strength of Rhiannon & Kayleigh for fighting to get this heard, and for all of the other families & NHS staff who came forward to make sure this wasn't ignored.

Heartbreaking.

Thinking of all the women and babies and children and young people and families affected

Going to see what I can do to raise awareness through work.

I'm in another country. I'm constantly startled at how frequently forceps are used in UK delivery, based on the stories I hear. I commented on this on MN, and had a couple of very patronizing nurses telling me that forceps are only used when there is no alternative. How come they are used so much more rarely in every other developed country, then? There is definitely an ideological element with it. Plus, I suppose yanking babies out is cheaper than doing surgery.

Horrible experience here too, luckily no ill effects on the baby but for years I felt that he had been born under a curse as the midwife was so horrible to me. Memorably she said 'I'm not in the mood for chatting' when I asked her a question. I did complain and was totally gaslight about how I must have misinterpreted words of encouragement!!

Heartbreaking, shocking and yet at the same time, entirely unsurprising, because we all know women who have suffered horrendous treatment during pregnancy and birth.

What happens now? It is screamingly clear that this is not just a problem in one trust. The attitudes that lead to these deaths and injuries are endemic within the professions, nationally, it would seem. What have the Royal Colleges said? The universities training the next generation?

Rhiannon and Kayleigh have done their bits now, they can rest and finally have space to grieve their daughters. The professionals now need to pick up the baton and effect the changes needed, not just in Shrewsbury but for every mother across the country. And they need to be seen to be doing so as well. We need to keep our eyes on them.

@DottyHarmer

I’m not sure it’s misogyny, in fact quite the opposite as it was the drive for natural births after the perceived over-medicalisation of childbirth.

When ds was born natural childbirth was the only thing and in fact there was quite a bit of Caesarian shaming amongst other mothers making women feel they’d failed for not doing it “properly”. It was all birth plans and the idea that a birth is under the mother’s control. No wonder people were bewildered and disappointed afterwards when a bit of whale music and three puffs didn’t cut the mustard.

I had a horrific delivery. I nearly died and was in hospital for two weeks. Ds was sickly. The care was awful. Some of the midwives were mean and lazy (I saw one at night with earplugs in doing Take a Break puzzles). I was given a private room (to avoid distressing the other mothers!) and the ward manager shouted at me and demanded to know why I was there (whilst I was having a blood transfusion). The cleaner had special needs and they were unable to clean properly. The loos were full of blood and all sorts and the cleaner was just pushing the mop around smearing it farther around.

I am happy to say that when I went there again they had had a revamp and it was, although horribly busy, much, much better organised and although I had another difficult birth they seemed keener to offer support and intervention.

I'd argue that's still misogyny. Some women enthusiastically buying into a concept doesn't make it not misogynistic, and I don't think your experiences can be divorced from your status as a female.

Ultimately, the ideology at the root of what happened in Shropshire couldn't have come to exist without a toxic brew of biological essentialism and sins of Eve attitude. And the neglect happened because it was women's bodies, too.

Absolutely devastating. The families' experiences are heartbreaking.

I too am unsurprised after my experiences.

Absolutely heartbreaking and horrific to read. Also very triggering. Women are treated appallingly by the NHS. And it's not just male Dr's and nurses, I've had the most awful comments and treatment from midwives in all of my births. There is a culture of bullying, intimidation, trivialising and negligence in maternity services. The problem is most women are just so shell shocked and glad to have made it out alive that they don't go back to revisit the trauma or complain. My heart is broken for the families affected, and I keep thinking we could have been one of them.

Maternity care is so consistently poor in my area that if you come across a midwife who is genuinely caring and OK (not good, just ok) at her job then you feel extremely grateful and lucky. I had 2 near misses and the cruelty of the midwives and Dr's is something I'll always carry with me.

This is heartbreaking but not shocking at all. I expect my local trust is much higher rated but it too failed many women and there have been countless avoidable deaths of mothers as well as babies.

We should also remember that its not just maternity services. Most of the NHS is now in a state where avoidable deaths are the norm and poor care is the best that can be achieved due to funding and lack of staff.

Can only agree the women who instigated this investigation are heroes. My heart goes out to everyone affected.

It is horrendous beyond words. Those poor women and their babies 💐 Something has to change. Poor care is excused time and time again.

@GrannyBloomers

This is heartbreaking but not shocking at all. I expect my local trust is much higher rated but it too failed many women and there have been countless avoidable deaths of mothers as well as babies.

We should also remember that its not just maternity services. Most of the NHS is now in a state where avoidable deaths are the norm and poor care is the best that can be achieved due to funding and lack of staff.

It is, but there is a lot that's specifically female and maternity related about this. And bear in mind the investigation covers a period beginning in 2000. Not to say the NHS was perfect then, it certainly wasn't, but the funding and staffing situation then was very different to what it is now. This is about ideology as well as resources.

My heart absolutely breaks for these families. I was absolutely rocked to my core reading some of the detail of the report yesterday. Let's hope this signals a real moment of change for this CCG and the NHS more widely.
I've been lucky enough to receive excellent care in the different hospitals I had my children in - of course this should be standard and consistent across the NHS, like others have previously said.

I agree with Hardy. This goes back a long way and the NHS can't play the underfunded card. While I'm sure the actual lines in a budget for lots of senior NHS manager salaries are small compared to the overall budget, the fact many of them were and are paid way, way above almost all (if not all) other parts of the public sector shows how cut off they are from oversight. And the oversight mechanisms failed abysmally too.

Being that cut off from the outside, from the real world, seems to have helped these organisations ignore women and - as is reported - blame them.

You don't need to be funded well, in order to treat women like human beings.