The head of a probe into the biggest ever NHS maternity scandal has warned similar tragedies could be unfolding at other hospitals.
Top midwife Donna Ockenden sounds the alert after a new report shows NHS staff now feel unable to speak up about dangerous care practices at more than a third of hospitals.
The findings come a day after the Ockenden report revealed hundreds of babies died after poor care at Shrewsbury and Telford Hospitals NHS Trust (SaTH).
Staff concerns were ignored and medics feared they would be targeted and their jobs would be in danger if they flagged up problems.
The Mirror can also reveal midwives were even “told off” for pulling the emergency buzzer to get support from more senior medics when things appear to be going wrong with a pregnancy.
Today a report from the National Guardian’s Office reveals the experience of designated Freedom to Speak Up Guardians amid continued NHS staff shortages.
The proportion of staff who feel safe to speak dropped last year by more than three percentage points to 62%.
Ms Ockenden said: “What we saw here at SaTH was a set of circumstances that could potentially be replicated elsewhere.
“The foundations of this was a failure to listen, a failure to investigate, a failure to learn and a failure to change.
“Therefore this was a failure to safeguard patience. There is the possibility that that could happen elsewhere... there are lessons that should be learned across the wider NHS system.”
Maternity staff even allege being told by senior managers not to talk to the Government enquiry.
The shocking probe revealed more than 200 potentially avoidable deaths, including 131 stillbirths and 70 neonatal deaths.
There were a further 29 cases of severe brain damage and 65 cases of cerebral palsy linked to poor care.
Nine women were also found to have died following mistakes.
It is feared they are linked to systemic problems in the NHS linked to short staffing on maternity wards and not listening to parents’ concerns.
Many women were prevented from having lifesaving C-sections until it was too late.
Ms Ockenden said she had SaTH staff contact her as recently as Tuesday saying they were “frightened to speak out” and “fearful of their job”.
She said: “We had only 109 staff come forward and then 11 withdrew literally as we were finishing our report. This is completely unacceptable.
“For the vast majority it was because they said they were frightened that what they said could be linked back to them.
“Other colleagues came forward and said that the reason why staff hadn’t come forward was number one, that they had been advised not to, and number two, they were fearful of reprisals, and number three, they were fearful for their jobs.”
Ms Ockenden said the damaging culture of fear meant there was evidence of ongoing poor care at the scandal-hit trust.
She used the example of community midwives being used in the hospital to deal with the most complex pregnancies.
She added: “Because of shortages of staff, community midwives were being pulled into the main unit. There was evidence that community midwives were being given the most complex case on the labour board.
“Community midwives have got a certain skillset, and that’s a really valuable skillset, but that’s not to look after the most complex lady on the labour ward.
“We know that. That’s A-B-C maternity. And there were instances where staff were being told off pulling the emergency buzzer.”
A key Ockenden recommendation is that safe midwifery staffing levels be enshrined in the NHS which would require between £200 million to £350 million of additional funding.
The NHS has so far been granted £127 million.
The Freedom to Speak Up Guardians’s report showed a drop of 9% who agreed that senior leaders support workers to report concerns, to 71%.
Dr Jayne Chidgey-Clark, National Guardian for the NHS, said: “This gives me cause for concern.
“Senior leaders should discuss the findings of this survey with their Freedom to Speak Up Guardian, and their workers, and look at their plans to continue to improve the speak up culture in their organisations.
“As the sector works to recover from the pandemic, leadership in healthcare has never been more pressured.
“A strong speak up culture is essential in delivering high quality and safe services and supporting the wellbeing of workers.
“Guardians can be a significant source of support for leaders in this, as they share themes of what workers are speaking up about - whether those are patient safety concerns, ideas for improvement, or issues affecting their work or wellbeing.
“But to help create the right climate for change, leaders must listen and act on those concerns.
“Collaborative and compassionate leadership is essential to retain the loyal and committed workers who have given so much over the past two years.”
Louise Barnett, chief executive at SaTH, said: “We always encourage and enable colleagues to speak up and remind all our employees that they can raise any concerns through a number of channels confidentially - whether it’s about patient safety or their own personal welfare - and know that if they do, they will be supported, listened to and the appropriate actions will be taken.
“Through initiatives such as Freedom to Speak Up, an online platform for staff to anonymously raise issues, executive drop-in sessions, and wider cultural change work, we have made progress, but we know that significant improvements are still required to get to where we want to be.”
