Ockenden report 2022: Three mums whose lives were changed forever by NHS maternity scandal
Three mothers left traumatised by the care they received at Shrewsbury and Telford Hospital NHS Trust have opened up to ITV News Central about their experiences.
It comes as senior midwife Donna Ockenden has today released her review into Britain's largest maternity scandal, in which hundreds of mothers and babies died or were left injured.
Charlotte Cheshire gave birth to her son Adam in March 2011. She says her pregnancy was straightforward, but the delivery was anything but.
"Sometimes a child is born and they have a disability and it happens and nobody knows why. But in this specific instance, I do know why. And I know it could have been prevented."
"I love my son unconditionally, exactly as he is," says Charlotte Cheshire.
"But" she adds, "at the same time, what happened to him at his birth is effectively a life sentence."
"Sometimes a child is born and they have a disability, and it happens and nobody knows why. But in this specific instance, I do know why, and I know it could have been prevented."
Charlotte told ITV Central about the "horrific" experience she had giving birth.
"During the labour, I haemorrhaged and lost nearly a litre of blood, she said.
"They had to stitch me up to save my life, I can still remember them stitching me up internally. I was screaming. It just it was horrific."
After the birth, Charlotte and her husband Chris thought they were through the worst of it.
"At that point, we thought that despite the drama of the birth and everything that had gone on, Adam was here, he was alive," she said.
It wasn't until the next morning that it became clear that things were far from OK.
'He stopped breathing. He was suffering from constant seizures. His whole body was convulsing.'
Charlotte realised Adam wasn't feeding and he was crying uncontrollably.
Despite telling the midwives she was worried, she says it took them several hours to take her seriously and shortly after Adam was rushed to intensive care.
Charlotte recalls the fear she felt: "Virtually as soon as he went through the doors, his whole body shut down. He stopped breathing. He was suffering from constant seizures. His whole body was convulsing."
"It eventually transpired that Adam was infected with Group B strep meningitis, so he spent the first week of his life on life support in a medically induced coma."
"At one point, I was allowed to take one photo with no flash, because of the seizures, and we genuinely thought that was the only photo we were ever going to have."
Charlotte says that Adam's experiences at birth have left her 11-year-old son with complex disabilities.
"Over the course of the last decade. It's become clear that he has very, very significant learning delays", says Charlotte.
"Developmentally, he's about age four. He still plays with toddler toys. He has very disordered, limited speech. He still needs 24/7 care. He's still in nappies at night and on long car journeys. He will never live independently. There is no possibility of him living independently."
'It's heartbreaking, not only that he won't see his son grow to adulthood, but he also won't know if anybody ever actually said sorry'
Two years ago, the family suffered another tragedy when Adam's dad, Chris, died from cancer.
"My husband had always been an incredibly healthy person. He was six foot six. He was fit.
"He did 23 miles sponsored walks. He was diagnosed with cancer on the same day that he was told he was terminal and ten months later he died."
Charlotte says her husband's biggest grief was that he was leaving his sons and she wishes he could have known that someone "will be held accountable" for what she and her son went through after he was born.
"It's heartbreaking, not only that he won't see his son grow to adulthood, but he also won't know if anybody ever actually said sorry," she adds.
"Initially we thought we were the only ones," recalls Charlotte before adding: "We thought, well, it was an accident. Sometimes these things happen and it's horrible, but it's an accident."
She continued: "But then we discovered that we were only one of thousands and thousands of families and up until this point, nobody has taken responsibility for that."
"Up until very recently the hospital was still describing us as historic cases, and that is just so dismissive because it's not history to me, it's my life and it's my life forever."
In a statement, the NHS trust said: "We take all cases extremely seriously and review each case individually.
"Having reviewed this case we have identified that there were failings in care, for which we apologise to Charlotte and her family."
"We would like to reassure all families using our maternity services that we are listening and acting on feedback.
"We recognise we still have further to go and I’d like to reassure mums-to-be and their families that we are working to ensure our care is aligned to best practice guidance."
"I said to my husband that when he comes, we're going to have a celebration, but instead of having the celebration, we were preparing a coffin for him."
Kamaljit Uppal had an outfit picked out to bring her baby boy home in.
"His first outfit, which was a Winnie the Pooh, he was going to come out with that. That was his first outfit. And the rest of what it would have been wearing at home, to go out and about with family."
She gave birth to her son Manpreet in April 2003 but he died just two hours later.
Kamaljit says despite her baby being feet-first, she was told she couldn't have a Caesarian section.
"The knees came, my waters broke and I jerked because it was so different frommy previous deliveries and I started getting scared," says Kamaljit.
Kamaljit says she "begged" the nurse for a C-section and was again told "no".
She says the doctor then also told her "no, you can have a normal birth".
"I said 'I'd prefer a C-Section, if it's going to be complicated, to save the baby's life', and he says, 'no, you're fine. You can have a normal birth. You’ll manage', so I started delivering and the feet came out."
Kamaljit says she continued delivering her son feet first and he got stuck, it was then she was sent for an emergency C-section.
"I knew what I was having so I was looking forward to him," explains Kamaljit, before adding: "And I said to my husband that when he comes, we're going to have a celebration, but instead of having the celebration, we were preparing a coffin for him."
"My world turned upside down," she added - "that was two of us that went in, and only one of us that came out.
"That's a massive hole in your heart. He was a precious little man and he was beautiful."
Kamaljit said when she was sent home she felt "empty" and had suicidal thoughts.
"I didn't want to live," she says, "nobody told me anything and I had no counselling".
"Was it me? What did I do wrong to them? Why didn’t they explain everything to me? Was it my fault?"
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It was in 2017, fourteen years after the birth of her son, that Kamaljit heard news surrounding the scandal at the trust on TV.
"I said to my husband, 'you've got to come and listen to this' and my legs went like jelly spaghetti," she says, "when I heard there were so many deaths I went into shock. I was gobsmacked that it was still going on."
"I've waited this long, but I'm going to get closure finally, and I'll be happy for that. I just hope I get justice, for Manpreet, for him."
The director of midwifery at SaTH previously told ITV News Central: "I am truly sorry for Mrs Uppal’s experience under our care and for the sad loss of her son, Manpreet."
The trust says it continues to work with feedback and recommendations from the review to make improvements and prevent the same mistakes from being made.
"I didn't know how I was going to carry on, how I was going to just go through a daywith the pain and not knowing what my body was doing, knowing something waswrong."
Following her maternity care at Shrewsbury and Telford Hospital Trust Andrea Bates gave birth to a healthy baby girl, but she says her body will never be the same again.
"Eva has recently turned seven, I can't quite believe where the seven years have gone and I'm still looking at my body isn't fully fixed", she says, "I haven't returned to normal and I doubt that I ever will."
Eva was born without any health complications in February 2015, but her birth took thirty-six hours and left her mother in excruciating pain.
Andrea suffered a haematoma and her stitches became infected.
She was also later diagnosed with a prolapsed bowel, for which she has had to have multiple surgeries.
"Going to the toilet was unbearable," says Andrea, "I just had to let it happen, and a lot of the time it would just happen. I wouldn't necessarily be in the bathroom, I'd be downstairs.I'd stand up. Just movement and I would just have an accident, just go to the toilet oreven in bed."
Andrea says the complications left her feeling "mortified" and "like a freak". "I didn't know how I was going to carry on, how I was going to just go through a day with the pain and not knowing what my body was doing, knowing something was wrong" she adds.
"I have so many emotions inside, said Andrea - "one minute I could just cry and cry, and never stop. And I'm also feeling angry that what happened to me, what was done has changed my life completely it's changed our family's life."
"We didn't have any more children because of what happened to me. I know that I'll never be the same as I was. My body will physically never be the same as it was."
The physical trauma has also impacted Andrea's mental health.
"I suffer with PTSD, anxiety, depression and panic attacks. I just want to feel normal again. Me. The me that I used to be."
"Because you couldn't look at me and physically see anything, I felt like I was a fraud, that it was in my head and I was worried about what people would think."
Andrea says the complications arose because when her pregnancy got to 36 weeks, Eva was still breached.
"I did everything I could to try and get her to - and she didn't turn" says Andrea.
"We had a long chat [with staff] about having her turned, and I said that I didn't want to," she recalls. "I was made to feel very guilty about it, that it perhaps wouldn't be doing the right thing for our child," she said.
Andrea says she went into the birth "very open minded".
"I was thinking, you know, if I have to have a Caesarean section, then that's fine. If it's a natural birth, that's great. Whatever I need to have a healthy baby and everything to be okay."
"I was under the impression that I'd be going straight in and having the caesarean section, which we were happy about," says Andrea.
"They told me not to push, which was the hardest thing ever"
She added: "It was awful because I was so scared. I felt like I was holding on for dear life and if I let go something was going to happen, something was going to give. I felt like I might do damage if I didn't hold on."
"It was becoming an ordeal and the goalposts kept changing. It was 4 o'clock caesarean, then it was 'we'll keep you on track a little longer' then 'we'll do a caesarean'."
"I was frightened at this point. I just kind of wanted the whole thing to be over" she said.
Eva was eventually delivered naturally.
"So on the final third push they delivered her, they pulled her out of me and they put her on my chest" says Andrea.
"But then I started to panic because I realised that I couldn't feel my arms properly. I lifted them up and I was paranoid that I was going to drop her because my arms were numb."
"I felt broken. I was scared. I was a new mum. Then I got all of this pain and I just felt that they thought 'this is normal, you've had a baby, you're going to be in a bit of discomfort', but I didn't know what was going on and I just had to take the reassurance that it was normal to have all this pain."
Andrea was sent home with Eva the following day.
"It was when I went to use the bathroom and I was trying to go to the toilet and the pain was excruciating" she says, "I just felt this hard lump underneath and it felt like my bowels had come down. It just felt like it was in the wrong place. It was just sheer panic."
"I was that scared I had to get my husband to bring my mum round because I just didn't know what was what was going on."
'I feel like I've missed out on the little things that perhaps are not important. The things we take for granted, just the daily activities, just being a mum.'
"I felt lonely and isolated because I realised that I couldn't carry on my life as normal. I couldn't do things that you do with a newborn baby."
"We didn't go out of the house for months. There are a lot of people that never met her as a baby because I didn't want to see anyone. I didn't take her to toddler groups until she was about two."
"Even now I do prefer to stay at home because of it, because I feel safer that I've got my own comforts at home and I've got the bathroom here if I need it."
"I feel like I've missed out on the little things that perhaps are not important. The things we take for granted, just the daily activities, just being a mum. Going out and showing off your baby because she is my pride and joy."
"If something had happened to her I would have given up a long time ago," says Andrea. "She’s the one thing that's kept us going as a family, really, you know, and I'm so grateful that she's okay."
"But I do feel there are things we haven't done because of what happened to me. Whether that's because we're always at the hospital or I just can't physically do things."
"I would just be at home in pain lying down on the sofa or even just lying on the floor because that was the most comfortable place to be."
The trust says it will continue to work with recommendations from the review and other inspections to provide the best care for mothers and babies.
Andrea and Kamaljit were both clients of Shoosmiths.
Shoosmiths’ clinical negligence specialist partner Kashmir Uppal, who is representing several of the families involved in the tragedy, said: “What happened at the trust was beyond horrendous, beyond tragic, it’s unbelievable and unforgivable.
"This should not have happened.
“There were failings across the system for such a long period of time and there were deliberate failings to investigate, to learn, to make changes.
“With the numbers of still-births and neo-natal deaths, why was this not picked up earlier? Why was there no national audit of these numbers?
"Why wasn’t it seen that this trust was an outlier in terms of their numbers against other trusts.
“Why did it take two women who lost their babies to fight for this review which started with 23 cases and then looked at 1600 cases over a 20-year period.
"This is not just restricted to failings with the trust but also failings nationally to pick this up.
“There were many red flags but no-one acted on them.
"There were failings in clinical governance amidst a toxic culture with people working against each other with this culture that pushed for normal births and to avoid caesarean sections at all costs.
“We are seeking redress for the families and compensation for what they have gone through, so at least they can then have some recognition for the failings in their individual cases.
“This has been a long period of time. The families just want to get on with their lives now.
“If the recommendations in the report are implemented and this results in better maternity care then this will support the families moving forward.
"The recommendations must be implemented. Action has to take place now.
“All we want is for this period of time in a women’s life to be a really happy time and not thetragedy that happened at Shrewsbury and Telford NHS Trust.”
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