When Sarah Hawkins started having contractions, the midwives at Nottingham City Hospital repeatedly turned her away, saying she was not yet in labour. Six days later, Sarah arrived at the hospital to give birth, only to be told that her baby, Harriet, was already dead. An independent review would later discover that Harriet’s death in April 2016 was “almost certainly preventable” and occurred due to gross negligence, from “lack of midwifery leadership’, “inadequate processes to support communication of clinical information,” “lack of governance in relation to reporting serious clinical incidents” to a “poor safety culture.”

Lamentably, Harriet’s death was not an outlier, and it transpired that 13 catastrophic failures had occurred before she was delivered stillborn. Six years on, and a lack of staff, training and oversight still plague maternity services countrywide. At the end of March, the 234-page review on Shrewsbury and Telford NHS Trust by senior midwife Donna Ockenden was published, exposing one of the biggest scandals in NHS history. She included a litany of failures, including a staggering 1,592 clinical incidents from 2000-2019. It  gravely revealed that 201 babies – including 131 stillbirths and 70 neonatal deaths – and nine mothers had died due to “repeated failures over two decades”, with many others left with life-long conditions resulting from their care.