In the months after the birth of her son Adam at Royal Shrewsbury hospital in 2011, Charlotte Cheshire just felt grateful that the NHS had managed to save his life after he contracted group B streptococcus meningitis (GBS) and was placed in an induced coma.
“My husband did a 23-mile sponsored walk for the hospital, raising just over £4,000, six months after Adam was born. We sent the money to them and had a photo op in the ICU with all the staff. We just didn’t know,” she said.
When a friend first suggested getting a lawyer to look into the possibility of medical negligence, she was offended by the idea, and it wasn’t until 2014 that she finally spoke to a solicitor. “For a long time, would you believe, I actually felt guilty for calling a solicitor. I thought we should be grateful. Looking back on that now, how naive was I?”
Adam, who was left with severe disabilities as a result of the infection, was one of 23 maternity cases at Shrewsbury and Telford NHS trust brought to the attention in 2016 of the then health secretary, Jeremy Hunt, who ordered a review into the trust led by senior midwife Donna Ockenden.
“Back then it was 23 cases, and I remember that number in itself seemed shocking to me,” said Cheshire. Since then the investigation has swelled enormously to include 1,862 cases, including stillbirths, neonatal deaths, maternal deaths and babies born with brain injuries. It has become the biggest maternity scandal in NHS history.
In June 2020 West Mercia police announced they were launching a criminal investigation into the worst cases, while Ockenden’s interim report in December 2020 identified a pattern of failures at the trust, including a reluctance to conduct caesarean sections and a tendency to blame mothers for problems.
But her final report, published on Wednesday after a five-year investigation, is a damning inquiry into how more than 200 babies died or were left brain-damaged due to inadequate care.
“So many families have been waiting for this for so long. There is an element of outraged relief for many I think. Yes, there is grief, there have been tears, but there has also been anger. The maelstrom of emotions have been here today,” said Cheshire.
“It’s utterly devastating to know not just what happened to my individual family, which was bad enough, but the fact it happened to so many other families as well. In 2009 three separate babies died within eight months of each other and they didn’t look into that. It’s staggering.”
She said many of the affected families see the report as the “final closure” in their battle for justice. “For other families, like mine, who are still waiting for the outcome of a court case, this is an important step along the way. But this still isn’t the end, some of us are still fighting,” she said.
The campaign for a review was spearheaded by Kayleigh and Colin Griffiths, whose daughter Pippa died in 2016 after contracting GBS during birth, alongside Rhiannon Davies and Richard Stanton, who lost their daughter Kate in 2009 shortly after she was born.
Davies had notified midwives about reduced movements towards the end of her pregnancy but she was reassured she was low-risk. After she was born, Kate was pale and floppy, and grunting (a sign of respiratory distress), but staff failed to act. Although she was airlifted to a hospital in Birmingham for treatment, she died a short while later.
Pippa was born at home, and Griffiths called midwives repeatedly when she quickly started displaying symptoms such as no interest in feeding, noisy breathing and vomiting. She was repeatedly reassured everything was fine, before Pippa stopped breathing and was airlifted to hospital, where she subsequently died.
Davies and Griffiths bonded over the similarity of their experiences and, suspecting they were not the only ones who had been let down by the trust, gathered together the 23 original cases that triggered the review. The final report will conclude their years-long fight for justice.
“Up until the inquiry, we still thought we had just had bad luck. So thank goodness for Kayleigh and Rhiannon,” said Cheshire. “In all of the years following, every single time the numbers have gone up, as they have exponentially, it’s been a shock. You just think blimey, can it get any worse? And all those emotions and shock have been spread over so many years.”
Cheshire now lives in Newport, Shropshire, with 11-year-old Adam, who is hearing impaired, visually impaired, asthmatic, autistic and has learning difficulties. He requires 24/7 supervision and will never be able to live independently.
“He’s gorgeous, and he’s lovely, and he’s scrummy and he’s my son and I love him to pieces. But it didn’t have to be this way,” she said. “Of course I don’t believe that disability in and of itself is some kind of tragedy. But this was a situation that could have been very different if the hospital had noticed what was going on.”
She believes that staff let her down by not warning her of the risks when her waters broke and labour didn’t start for more than 18 hours, during which time she passed on the GBS infection to her son. She also felt they failed to act quickly enough when Adam didn’t feed overnight, was crying with a high-pitched cry and was grunting.
“By the time I was awake and saying there are issues, they were still dismissive until it was nearly too late,” she said. “The signs were there and as medical professionals they should have known.”
For Cheshire, and many of the families affected by the Shrewsbury maternity scandal, their main priority is ensuring the report brings lasting change.
“I’m not particularly interested in blaming anyone,” said Cheshire. “What I’m interested in is: how can we stop this happening in the future? We’ve got the skills, we’ve got the technology, we’ve got the medicine for things to be, maybe not perfect, but a lot safer than they were in Shrewsbury. How can we protect families from this heartbreak?”
