The inquiry reviewed 1,592 clinical incidents involving mothers and babies spanning between 2000 and 2019.

Donna Ockenden said she was “deeply concerned” that families continue to contact the review team in 2020 and 2021 raising concerns about the safety of maternity care they have received at the Shrewsbury and Telford Hospital NHS Trust.

“Some of these recent families contacted us with reports they wanted to share with us. We haven’t been able to include them fully within the review but what we have seen is that the themes within their reports seem to echo concerns we have previously seen during this review.

“Seeing these repeated themes is a cause for grave concern.”

Here is what Donna Ockenden said:

“Throughout our final report we have highlighted how failures in care were repeated from one incident to the next.

“For example, ineffective monitoring of foetal growth and a culture of reluctance to perform Caesarean sections resulted in many babies dying during birth or shortly after their birth.

“In many cases, mother and babies were left with life-long conditions as a result of their care and treatment.

“The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved.

“There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths.

“What is astounding is that for more than two decades these issues have not been challenged internally and the trust was not held to account by external bodies.”

The inquiry findings into the UK’s biggest maternity scandal are out.

It says there were a total of 295 avoidable baby deaths or brain damage cases as a result of poor maternity care between 2000 and 2019 at Shrewsbury and Telford Hospital NHS Trust.

Broken down, this was 131 stilibirths, 84 brain damage cases and 70 neonatal deaths.

Mothers and babies died or suffered major injuries due to “repeated failures” by the trust, who presided over catastrophic failings for 20 years and did not learn from its own inadequate investigations, according to the inquiry.

Several mothers died after failings in care, while others were made to have natural births despite the fact they should have been offered a Caesarean.

Some babies suffered skull fractures, broken bones or developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries.

An interim report into the Shrewsbury maternity scandal was published back in December 2020.

It found more than a dozen women and more than 40 babies died during childbirth at the trust because of a culture that denied women choice and subjected hundreds of families to unsafe care.

In some cases women had been medicated and forced to undergo traumatic forceps deliveries – leaving babies with fractured skulls and broken bones – because of a culture of trying to avoid deliveries by caesarean section.

You can read over it here ahead of the full report’s publication:

“What seems to happened is the trust had a particularly strong focus on keeping caesarian births low to a degree that was almost obsessional,” Kim Thomas from the Birth Trauma Association says.

She gives her insight on the scandal ahead of the report publication:

He warned patients would be exposed to unnecessary harm unless action was taken.

Our heath correspondent at the time, Shaun Lintern, reported:

Families affected by the largest maternity scandal in NHS history are awaiting the publication of the inquiry later this morning.

Here is one family affected: Rev Charlotte Cheshire and her son, Adam.

Adam was left with severe disabilities after staff failed to administer antibiotics for seven hours when he caught an infection during birth in March 2011.

An NHS investigation previously found hospital bosses at Shrewsbury and Telford Hospital Trust were more concerned with reputation management than addressing patient safety concerns in its maternity department.

Here is our report from the time:

Jeremy Hunt also said NHS staffing was “a very important issue” and the health service is short of thousands of midwives.

“I believe Donna Ockenden is going to say some very strong words about that,” he told BBC Radio 4’s Today programme.

“And I’m extremely disappointed that today the government looks at to vote down an amendment to the Health Bill, which has come back from the House of Lords, which would make sure that we didn’t have these kinds of staffing shortfalls.”