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BBC News-20220330-10:00:00

the headlines at 11... an investigation finds that more than 200 babies might have survived if they had received proper care at the shrewsbury and telford trust in shropshire. senior midwife donna 0ckenden led the damning report. we now know that this is a trust that failed to investigate, failed to learn and failed to improve. this resulted in tragedies and life changing incidents for so many of our families. 0ne mother tells the bbc about her baby boy jack — who died when he was just 11 hours old. and i said, well, is that it? you don't know why he's died? and then they said, well, we don't know what else to tell you. and i was like, well, i want a postmortem because a babyjust doesn'tjust die.

Investigation , Headlines , 11 , Fouryears-trust , Donna-0ckenden , Report , Babies , Care , Trust , Led , Shrewsbury , Shropshire

BBC News-20220330-09:22:00

without fear of reprisals. the trust must also ensure they continue to make progress on the local actions for learning and immediately essential actions from the first report. this is a trust with a significant amount of work to do to continually improve the safety of maternity care with their own staff coming forward in the last few weeks to tell me they wanted an assurance that the trust would still be monitored very closely and that in the words of a current member of staff, the trust must show real evidence of change, notjust say in the previous they have changed. some of the key local actions for learning, and they are included in more detail in the report, incidents must be graded appropriately with a level of harm recorded as the level of harm the patient actually suffered. correct investigation process in procedures and

Fouryears-trust , Report , Actions , Learning , Progress , Reprisals , Fear , Maternity-care , Staff , Work , Safety , Amount

BBC News-20220330-09:31:00

who have lost babies, lost mothers. she began by paying tribute to families, because it was thanks to the tenacity of some of the parents affected that all of this came to light, wasn't it?— affected that all of this came to light, wasn't it? yes, you are left wondering _ light, wasn't it? yes, you are left wondering if _ light, wasn't it? yes, you are left wondering if the _ light, wasn't it? yes, you are left wondering if the two _ light, wasn't it? yes, you are left wondering if the two families - light, wasn't it? yes, you are left| wondering if the two families who really got the ball running with this, they both lost baby girls a few years apart, and they started digging, they trusted their instincts that things had gone catastrophically badly for them, and they realised that the trust was lacking in so many areas. they started digging for more cases and they got 21 together, 23, including those two that campaigned, and went to the then health secretaryjeremy hunt and got this investigation going. priorto hunt and got this investigation going. prior to that, there had been investigations, but they had been in—house. this was the trust

It , All , Families , Babies , Mothers , Parents , Light , Some , Tribute , Wasn-t , Thanks , Tenacity

BBC News-20220330-10:15:00

making answers,? for accountability, for making sure no other families answers,? for accountability, for making sure no otherfamilies injure what we have. you have heard that was bought, what is your response to it? i was bought, what is your response to it? ., , ., ., ., ~ it? i am very grateful for the work of donna and _ it? i am very grateful for the work of donna and that _ it? i am very grateful for the work of donna and that she _ it? i am very grateful for the work of donna and that she has - it? i am very grateful for the work of donna and that she has very . of donna and that she has very clearly said that what happened that this trust was unacceptable and has to change. i am not entirely certain whether or not the trust actually has the ability to make the changes she mandates. i hope they will for obvious reasons but at least so far in the last 20 years they haven't shown any signs at being able to, i think it will be a case of watch this space and see what happens next. ~ ., , this space and see what happens next. ~ . _,, .., this space and see what happens next. we really appreciate you talkin: to next. we really appreciate you talking to us — next. we really appreciate you talking to us today. _ next. we really appreciate you talking to us today. best - next. we really appreciate you | talking to us today. best wishes next. we really appreciate you - talking to us today. best wishes to you and adam. with me now is rachel power, chief executive at the patient�*s association. thank you so much for your time today. i don't know if you are able today. i don't know if you are able to hear all of my previous guest and what she was saying but she was

Donna-0ckenden , It , Families , Work , Making-answers , Response , Accountability , Otherfamilies , Fouryears-trust , Reasons , Ability , Us

BBC News-20220330-09:10:00

and babies have been reviewed. this includes an early case from 1973 and the latest case from 2020. we now know that this is a trust that failed to investigate, failed to learn, and failed to improve. graded as having significant, category two, or major concerns, category two, or major concerns, category three, in the maternity care provided. when reviewing the stillbirth and neonatal deaths in the time period 2011 to 2019, the

Fouryears-trust , Babies , Case , 1973 , 2020 , Maternity-care , Concerns , Deaths , Stillbirth , Category , 2011 , 2019

BBC News-20220330-09:03:00

forward. leading this maternity review has been the biggest privilege of my life. it will remain with me forever and i would like to thank all of the families for the trust that they have put in my team and myself. my the families have asked me to thank the many journalists gathered here today, they have told me how important a role many of you have played in getting their voices and stories heard. they have asked me to thank you all for your professionalism and your kindness. they have told me that some of you cried along with them on hearing the accounts of what happened to them. your support has been so important to them and thank you on behalf of the families. in the circumstances and in this place, there are families who have bravely decided to attend, and i know that you will understand that they have a

Fouryears-trust , All , Families , Life , 0urfinal , Maternity-review , Privilege , Stories , Voices , Journalists , Many , Role

BBC News-20220330-09:17:00

the review believes failings have persisted in some investigations as late as 2019 and the cases we considered as part of this review. although independent and external reports consistently indicated that the maternity service should improve its procedures, governance and investigatory, this message was lost investigatory, this message was lost in the trust which was struggling with other concerns. this meant the consistently throughout the review period, lessons were not learnt, mistakes and care were repeated and the safety of mothers and babies was unnecessarily compromised as a result. we spoke to staff members at the trust and documentary evidence also considered by the review team showed us that following serious incidents, there would be no follow—up from recommendations made. 0ne staff member told us this was not just the 0ne staff member told us this was notjust the maternity unit in chaos and under pressure, that was a whole

Donna-0ckenden-review , Part , Investigations , Cases , Failings , 2019 , Fouryears-trust , Concerns , Governance , Investigatory , Maternity-service , Procedures

BBC News-20220330-09:12:00

trust, hoping someone would do something. fouryears trust, hoping someone would do something. four years after her death in 2006, her mother went on the this morning show, she told me that over all those years raising concerns, she felt like a lone voice in the wind. at the same time as 0livia's mother was appearing on television, otherfamily 0livia's mother was appearing on television, other family suffered the death of their babies and only then did the health care commission review the trust. it failed to take the necessary action. this was a missed opportunity for the trust to learn. the external scrutiny of the trust had clearly failed and this is a theme that has been repeated again and again over many years. so many parents have told us they try to raise concerns but they were not listened to. through the tremendous

Fouryears-trust , Mother , Something , Death , Someone , Morning-show , 2006 , Four , Babies , Concerns , Family , Wind

BBC News-20220330-10:06:00

around implementation of our ieas immediate and essential actions, and the recommendations of other reports currently being prepared. this investment in work must be progressed at pace and continued for as long as necessary to ensure that no other family experiences the many tragedies described in our report. 0nly tragedies described in our report. only with a robustly funded, well staffed and well—trained workforce can families and government be able to expect consistent delivery of safe and compassionate maternity care locally and across england. 0ur correspondent rob sissons is outside the royal shrewsbury hospital. donna listing a damning trio of figures at the trust, that failed to investigate, fail to learn and fail to improve she said over the period under review, almost two decades. were it not for the persistence of

Actions , Work , Investment , Reports , Recommendations , Pace , Implementation , Ieas , Families , Report , Government , Family

BBC News-20220330-09:20:00

fact, this was added to the report in the final days before printing. section 1.32 will tell you, staff members describe the cleat on the labour ward at the trust with the culture of undermining and bullying. staff members describe they were negatively and seriously affected their mental health. 0ther negatively and seriously affected their mental health. other staff members describe the behaviour on the labour ward was so bad that they had difficulty finishing their shifts and cried secretly whilst at work. the staff declined for their direct quotes to be used because they were fearful of being identified. section 1.35 on page 184, a current staff member and maternity services at the trust spoke to the review team in early 2022, describe themselves as fearful to do so. the staff member said i really had to think very carefully about approaching staff voices when

Report , Staff-members , Section , Trust , Fact , Cleat , Printing , Labour-ward , 1-32 , Culture , Mental-health , Behaviour