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.

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.

I agree and it is the best example of women being failed and not listened to. I nearly died in childbirth due to a hospital acquired infection - the key to the story being not being listened to.
I still think that women's health is underfunded and has been all my life. But yes today the situation is much worse than it would have been in say 2000. As someone coming into menopause the current availibility crisis is just another kick in the teeth.

Given then number of people on here talk about the terrible attitude of staff, that is not a budget issue.

In terms of management salaries there is a tension caused by clinical pay scales. If you are getting the most senior consultants to move into management then their salary has to be above their senior consultant salary. And if you are a non-clinical manager with a comparable or more senior level of management responsibility then your salary cannot sit well below that of a consultant who is carrying out a management role (but possibly not a clinical role).

I read the BBC article and it’s heartbreaking how this toxic environment went on for over twenty years...the oldest couple in the BBC article had lost their baby in 2000.

My list is similar to a PP as to the causes of this:

1. NHS staff and budget cuts
2. The fact the nursing bursary was stopped for years causing a shortage of midwives specifically
3. The training of midwives has gone down from 3yrs to 1yr and with far less clinical training actually assisting at births. This has led to dangerous levels of incompetence in many midwives and maternity wards.
4. The pushing of natural birth as best without the competence to recognise its worst for complex higher risk pregnancies
5. The misogyny inherent in how labouring women are treated like cattle and dehumanised by the whole process in the maternity ward.

@AnotherNC22

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 only knew about GBS because a colleague at work whose daughter had been ill after birth encouraged me to pay for a private test. It was positive and the hospital would have given me antibiotics in labour but I ended up having a caesarean anyway. Son is now 11.

By the time I had my 6 year old the NHS hospital was doing testing (this wasn’t standard at the time, don’t know if it is now) and I was positive again.

@Lovelyricepudding

Given then number of people on here talk about the terrible attitude of staff, that is not a budget issue.

In terms of management salaries there is a tension caused by clinical pay scales. If you are getting the most senior consultants to move into management then their salary has to be above their senior consultant salary. And if you are a non-clinical manager with a comparable or more senior level of management responsibility then your salary cannot sit well below that of a consultant who is carrying out a management role (but possibly not a clinical role).

But compassion fatigue is linked to under funding and staff shortages. Stressed and burnt out staff will struggle to provide compassionate care. Staff go into survival mode and cut themselves off emotionally and are more likely to make mistakes. This sounds like an excuse I know but there is a lot of proven research into the impact of lack of funding, staff etc on patient care.

@LethargeMarg
That is a very good point.

Yes good point Lethe, in my case I know that the midwife was looking after other people at the same time and argued not yo take another because I heard it all. She was then made to take me and took it out on me!!

Yes, I also think the system has a lot to answer for when it comes to staff burnout and staff neglect of patients. Must be difficult to engage in quality patient centred care if you are on double shifts with a massive caseload, paperwork, inadequate support and supervision ect.

Many people said "this is going to hurt" was misogynist, but I don't think the show was condoning the neglectful behaviour of the doctor. More putting it in the context of a brutal system.

When it comes to nurses and even junior doctors they are at the bottom rung of a very hierarchal and rigid structure I hear.

But again, this isn't to excuse, just to put in context.

Compassion fatigue does not hold any water with me, i’ve been in a caring role for over 23 years wow whilst I don’t have people‘s lives in my hands so my stress levels are not gonna be compatible with medical staff I can still choose to do my job or I can choose to do my job with sensitivity and kindness and that’s what I do every single day.

Yes, who knows about other hospitals and the parents who thought 'it was just bad luck'
It's never too late to speak up

I’ve always felt that my DS was lucky to be born alive and without life changing injuries due to the neglectful and cruel care that we received in labour ( different hospital).
I’m sobbing at the memory of the harsh way I was treated, and DS is 32.

[quote BattenbergdowntheHatches]@LethargeMarg it’s also the inevitable result of HR policies that mean there will never be an consequences for NHS employees, no matter how vile you are to patients.[/quote]
Not true nurses and midwives are registered with the Nmc and are regularly called to account and lose their registration if they don't keep to the standards of the code- you can look up online to see action taken .

The hospital I gave birth at was full of similar horrific nonsense. I was told that it didn't have the staff to do a C-Section so I had to give birth "normally". I ended up with life-changing injuries from a forceps delivery.

@peterpomegranate it is sadly still not standard although some midwives will let you know about the private test that is available. I believe one of the mothers in this report has a separate campaign pushing for testing to be introduced as standard. I asked our neonatologist why this was the case and he said that apparently the UK rates of GBS sepsis are not different to countries where they do test. But try telling that to a mum who has or nearly has lost their baby to GBS sepsis or meningitis. He also told me that NICE guidelines dont even recommend preventive antiobiotics for future labours anymore - just increased monitoring post birth.

@user1477391263

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.

I'm pretty sure forceps are used in some sections as-well. If the baby is deep in the pelvis for example. Do the countries that use forceps less have fewer negative birth outcomes?

It's such a horrible idea that forceps deliveries are simply cheaper than a c section. But is that accurate?
I'd guess many women would be happier with a forceps delivery done well, rather than the major surgery of a c section.

Oh it's all so terrible. And deeply wrong that women historically have not spoken up about the trauma of childbirth. That baby loss is often treated as bad luck. If we speak up and keep speaking up and don't stop speaking up then things will have to change.

More funding and training. More education, research. Moving beyond the polarising of natural vs medical. Merging expert MW knowledge with expert obstetric knowledge.

Get the toxic staff out. Or/and increase training in psychology of childbirth - make it mandatory.

Force NHS maternity to progress out of a blame work culture into whatever it takes to stop damaging mothers and killing babies.

Women avoid these threads because nobody wants to think of the harrowing reality of child loss- but it is very real and not reading about it won't make it go away.

@Lovelyricepudding

Given then number of people on here talk about the terrible attitude of staff, that is not a budget issue.

In terms of management salaries there is a tension caused by clinical pay scales. If you are getting the most senior consultants to move into management then their salary has to be above their senior consultant salary. And if you are a non-clinical manager with a comparable or more senior level of management responsibility then your salary cannot sit well below that of a consultant who is carrying out a management role (but possibly not a clinical role).

I think attitude of staff can be traced back to staff shortage and stress. A MW friend told me MWs train, work three years and then leave. They're unsupported in high risk environments. Not my industry so I can't imagine- but I'm struck by the fact that these are people who originally go into midwifery to do good things. Something is seriously wrong with the system.

As an ex midwife I have been waiting for this report and it’s every bit as awful as I expected.

Women are not listened to.

Midwives are trained (or were) with the quaint notion of birth being normal, that’s okay as around 70% of births are “normal” by which I mean a vaginal delivery with no assistance needed. . However the system fails to note that this is more likely if

The woman has built trust in her caregivers
If the midwife is known to the mother
The midwife has provided a good 50% of the antenatal care and knows the history well.

The reality is a underfunded and understaffed system with not enough midwives and the focus on keeping costs down.

Most women will not have met the midwife who assists with their birth. Most women will have had little to no support during pregnancy from a midwife.
The NCT may be hated but at least they try to plug the gap of antenatal education.

Some midwives shouldn’t be allowed within 100ft of a labouring woman.
Nor should some doctors it has to be said too.

The time of lovely normal births has sadly gone, the system is too broken and women now need to have much more say over how their babies are born.

I wrote “no forceps” on my birth plan and told the consultant that I’d rather have a CS than be butchered . In the end DS was a failed induction so was born by CS anyway.

I left midwifery behind as I could no longer be part of a system that treated women so appallingly.

@Whiskyinajar

As an ex midwife I have been waiting for this report and it’s every bit as awful as I expected.

Women are not listened to.

Midwives are trained (or were) with the quaint notion of birth being normal, that’s okay as around 70% of births are “normal” by which I mean a vaginal delivery with no assistance needed. . However the system fails to note that this is more likely if

The woman has built trust in her caregivers
If the midwife is known to the mother
The midwife has provided a good 50% of the antenatal care and knows the history well.

The reality is a underfunded and understaffed system with not enough midwives and the focus on keeping costs down.

Most women will not have met the midwife who assists with their birth. Most women will have had little to no support during pregnancy from a midwife.
The NCT may be hated but at least they try to plug the gap of antenatal education.

Some midwives shouldn’t be allowed within 100ft of a labouring woman.
Nor should some doctors it has to be said too.

The time of lovely normal births has sadly gone, the system is too broken and women now need to have much more say over how their babies are born.

I wrote “no forceps” on my birth plan and told the consultant that I’d rather have a CS than be butchered . In the end DS was a failed induction so was born by CS anyway.

I left midwifery behind as I could no longer be part of a system that treated women so appallingly.

Gosh. What you've written is so relevant. I am overwhelmed by all these elements that contribute to a better birth. And saddened by how they're somehow not integrated into hospital guidelines. On one hand we do know much about childbirth but our society and maternity services are archaic. Is this because of misogyny? At its root do we/women accept our poor maternity care because we think 'it is what it is'....and move towards birth crossing our fingers.

www.dailymail.co.uk/health/article-1199156/Why-mothers-pain-childbirth--male-expert-midwifery.html? in 2009 by a male midwife who wrote text books and retired not so long ago.

More women should endure the pain of childbirth because anaesthetic drugs undermine the mother’s bond with her baby, an expert said yesterday.

Dr Denis Walsh said the agony of labour should be considered a ‘rite of passage’ and a ‘purposeful, useful thing’.

The pain prepared women for the demands of motherhood, he argued.

Dr Walsh, associate professor in midwifery at Nottingham University, criticised the ‘epidural epidemic’ sweeping the NHS, and said maternity units should abandon routine pain relief and embrace a ‘working with pain’ approach.

an article for Evidence Based Midwifery, published by the Royal College of Midwives, Dr Walsh said the NHS was too quick to give in to requests for pain-killing injections.

He said: ‘A large number of women want to avoid pain, but more should be prepared to withstand it. Pain in labour is a purposeful, useful thing which has a number of benefits, such as preparing a mother for the responsibility of nurturing a newborn baby.’

Only a man could come out with something like that.

Childbirth is a funny old thing, honestly none of mine hurt that much, I certainly wasn't screaming in pain for the most part, and perhaps is why I wasn't believed, I wasn't acting correctly. Everyone's experience is different and no more should mine be used as a yardstick than the woman who had an epidural from the get go.

I have a theoretical risk associated with an epidural which wouldn't be discovered until the needle went in, my birth plan had in big letters that they had to consult my notes and information from the consultant before considering any intervention.

I have just wrote a lengthy description of my two horrible childbirths on GN.It was52 and nearly 50 years ago now, not at Shrewsbury, but my heart goes out to those poor mothers and babies, I thought those days were over.

I read this report and I can't even find the right words.

I suffered from recurrent miscarriages before having my son and also had unexpected complications with him in the third trimester, all resulting in a planned CS.

I have PTSD and anxiety now because of all this and even though he's here safely, I still have terrors thinking about the what ifs, all the things that could've gone wrong, CS being refused and DS dying. My brother was born sleeping due to an undisgnosed illness and negligence that was never admitted. Ever since then, the fear has always been there. My mother has never been the same. So this issue strikes very close to my heart.

Rhiannon and Kayleigh, you are two very, very brave women. If you are reading this, please know that you have your village here and that we all support you and are grateful for your determination. Your beautiful children's legacy will live forever.

To Donna Ockenden, I read how deeply you were affected by preparing this report and yet you kept going to deliver for all mothers and babies. Massive respect for this.

I'm so sorry for all the families affected directly and also those who are traumatised now realising they may have had a near miss at Shrewsbury and Telford. It's absolutely awful and tragic

This should've never happened. What needs to happen for this to stop? There isn't enough money, there aren't enough midwives or consultants, and alongside some fantastic members of staff at maternity units across the whole country, there are some vile ones who should never be allowed to work with mothers or babies. What can be done if we're in such trouble already? This isn't just Shrewsbury, the same story happened in Cwm Taf in Wales recently and there's a lot more.

Apologies, I've missed the key paragraph in my post above - to even try to imagine that deepest fear becoming true like it happened to all these poor families is absolutely horrific. I am so incredibly sorry to all of them for the pain and grief they hsve to live with every single day. It's just unbearable that they've been failed so badly by the very people who were there to look after them and their babies.