Shropshire baby deaths scandal: Review under way after hospital board failings

The report, into the board of Shrewsbury & Telford Hospital NHS Trust, follows an investigation carried out by Fiona Scolding KC, which was commissioned by the trust after complaints from Rhiannon Davies and Richard Stanton in 2020.

Ms Davies and Mr Stanton's daughter, Kate, died avoidably while in the trust's care in 2009.

Campaigning by the couple ultimately led to the Ockenden Inquiry, which confirmed serious and harrowing failures in maternity care at the trust.

The latest report was sparked by their concerns about former board chairman Ben Reid and the actions of the board over maternity issues at the trust – and whether Mr Reid was a fit and proper person for the position.

Ms Scolding has concluded that Mr Reid was fit and proper, stating: "Mistakes were made – and not everything was handled as it could and should have been. I do not find however that any of these actions amount to 'serious mismanagement'."

She added: "The evidence shows that Mr Reid did take steps to seek to improve patient safety. The difficulty was trying to make such improvements when not given the relevant information to make a strategic difference and in the context of an organisation which was broken.

"He did not succeed but he did try within the confines of his expertise and understanding."

However, the report criticises the board's management and scrutiny of issues in maternity care, finding it was too accepting of information and decisions put before it.

It is also criticised over a delay in publishing a controversial report looking at the trust's maternity services, carried out by the Royal College of Obstetricians and Gynaecologists (RCOG).

The report had been commissioned by the trust in response to publicised concerns about its maternity services, however its publication was delayed after the trust disagreed with its findings.

It should have been published in 2017, but was held until 2018, with Ms Scolding saying the trust had tried to 'spin' the findings.

She said: "The way in which the report was published was unhelpful and sought undoubtedly to try and 'spin' the findings of the RCOG. This should not have happened."

The report also highlights the trust's response to criticism, stating: "When it felt under threat, it sought, on some occasions, to prioritise the reputation of the organisation above transparency and candour."

The board of the trust is also criticised for not interrogating the delay in the report's publication at the time.

Ms Scolding writes: "The fact of the delay in the production of the RCOG report to the main board should have been the subject of discussion at the board meeting.

"There should also have been consideration of whether the mechanism of oversight proposed by the trust’s executives was adequate, or if alternative processes for scrutiny and oversight should have been implemented. Whilst there was some discussion, this did not happen to a sufficient degree to satisfy NHSI in their report."

Ms Scolding also found failings in the way the trust had dealt with Ms Davies and Mr Stanton and their daughter's death.

She said: "There is no doubt that in respect of the death of Ms Stanton Davies [baby Kate], there have been obfuscations, difficulties, and failures."

Ms Scolding added: "The trust has not dealt with Mr Stanton and Ms Davies in an open and honest way. That is undoubtedly true."

The report was discussed at Thursday's meeting of the current hospital trust board, with members told a governance review was already underway over issues highlighted in the report.

The board's current chair, Catriona McMahon, Mr Reid's successor, also offered an unreserved apology to Ms Davies and Mr Stanton.

She said: "I would like to draw specific attention of the board to Ms Scolding's conclusion that it is undoubtedly true the trust has not dealt with the complaints in an open and honest way and for this I unreservedly apologise to Ms Davies and Mr Stanton."

She also accepted the findings over the RCOG report, stating: "We accept our handling as inappropriate and inadequate for all of the reasons set out by Ms Scolding in her report."

Non-executive board member Professor Trevor Purt said the report had made for a "chastening read".

Director of nursing Hayley Flavell added that it had been a "really difficult read".