Ockenden report: Criminal investigation into Shropshire maternity scandal ‘remains active’

Donna Ockenden speaking to families and the media

No arrests have been made or charges laid, but the investigation “remains ongoing and very active”, West Mercia police said.

Detective Chief Superintendent Damian Barratt, who is leading the criminal investigation, said: “We have been in close contact with the Ockenden Review and are, of course, aware of the release of the report today.

“Our investigation, named Operation Lincoln, was launched in 2017 to determine if there is any evidence to support a criminal case against the trust or anyone involved. This investigation is still ongoing and very active.

“This is a very complex and very sensitive investigation which required us to speak to a large number of people to gather as much information as possible. We are also consulting with a number of medical specialists to ensure that our investigation is thorough and that the best possible investigation is carried out for the families concerned.

“No arrests have been made and no charges have been laid, but we are engaging with the Crown Prosecution Service (CPS) as our investigations continue. We will fully review the report’s findings and provide appropriate evidence for our investigation.

“We do not underestimate the impact of the report’s findings and our ongoing investigation on the families involved, who suffered unimaginable trauma and grief that they still live with today. Our thoughts remain with them, and we can reassure the community that when there is an update on our investigation, we will share it first with the families involved and then with the general public.”

The investigation found that SaTH presided over catastrophic failures for 20 years – and failed to learn from its own inadequate investigations – that led to babies being stillborn, dying shortly after birth, or severely brain damaged.

Some babies have suffered skull fractures, fractures or developed cerebral palsy after traumatic forceps deliveries, while others have been deprived of oxygen and suffered life-altering brain injuries.

Several mothers were forced to give birth naturally when they should have been offered a caesarean section.

The report looked at cases involving 1,486 families, mostly from 2000 to 2019, and reviewed 1,592 clinical incidents.

A review of 498 stillbirths found that one in four people had “significant or major concerns” about the maternity care provided, which, if handled appropriately, could or would have resulted in a different outcome. Some 40% of these stillbirths were never investigated by the trust.

There were also “significant or major” concerns about the care provided to mothers in two-thirds of cases where the baby had been deprived of oxygen during delivery.

Overall, there have also been 29 recorded cases where the babies suffered severe brain damage and 65 cases of cerebral palsy.

Nearly a third of neonatal deaths had “significant or major concerns” about care. Yet the trust had only looked at 43% of them.

A total of 12 deaths of mothers were investigated, none of whom received care in line with best practice at the time. In three-quarters of these cases, the care “could have been significantly improved”.

Some women were blamed for their own deaths, the report said, while incidents that should have triggered a serious incident investigation were “inappropriately downgraded” by reliance on its own series of case reviews “to high risk”, which were “apparently to avoid scrutiny”.

Ms Ockenden’s report said this ‘meant that the true extent of serious incidents within the Trust’s maternity services was unknown over a long period of time’.

SaTH issued an apology following the release of the report.

Louise Barnett, chief executive of the Shrewsbury and Telford Hospital Trust, said: “Today’s report is deeply distressing, and we offer our most sincere apologies for the pain and distress caused by our failures as a trust.

“We have a duty to ensure that the care we provide is safe, effective, of high quality and always delivered with the needs and choices of women and families in mind.

“Thanks to the hard work and commitment of my colleagues, we have delivered all the actions we were asked to take following the first Ockenden report, and we owe it to the families we failed and those whose we care now and in the future to continue to make improvements, so that we provide the best possible care to the communities we serve.”


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