Feb 23, 2022

The mothers who helped uncover the biggest maternity scandal

The trust admitted that error but refused to accept criticism of its maternity care at the inquest into Kathryn's death, held in April 2003.An expert witness called by the coroner told the court, "In my opinion, Kathryn Leigh's need for resuscitation arose from incompetent management of her mother's pregnancy and labour". A lack of both midwives and consultants was a problem for years at the trust according to former employees that Panorama has spoken to. In recent years, he said, a gap developed between the management of the trust and its clinicians, which he says was mainly caused by a problem the whole NHS faces - the lack of good quality, trained managers who have as much professional accountability as clinicians. The problem raises significant questions for all NHS bodies charged with overseeing trusts because the issue was highlighted as a problem at the Shropshire trust as far back as 2007.After the failure had been noted as a contributory factor in two babies being born with severe brain damage, in 2004 and 2005, the Healthcare Commission, the regulator at the time, wrote to the trust demanding action to ensure the problems "are not repetitive and that learning is taking place". Its reports, following inspections of the trust in October 2014 and December 2016, make no mention of a problem with monitoring baby's heart rates.

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