"I was left with an 8 cm tear inside my vagina after giving birth."

"As Charlotte Hadley went into labour with her first child, little did she know that she would become yet another harrowing case in the ‘shocking failings’ of one disgraced NHS trust."

Trigger Warnings: Detailed Medical Talk, Life-changing Injury, Infant Death

Elton John and Boney M. are probably not the usual soundtracks of choice for expectant mothers in the throes of labour. But as Charlotte Hadley furiously puffed away on the gas and air at The Princess Royal Hospital in Telford, 'Step into Christmas' and 'Mary's Boy Child' played on the hospital radio of the maternity unit.

As the station was about to broadcast its Top of the News Hour Bulletin that December evening in 2020, it was Charlotte’s husband, Ryan, who noticed one of the midwives quickly scurry across the room to turn it off. He knew the reason why.

Earlier that same day, news had broken about the release of an interim report into Britain’s largest maternity scandal. The Ockenden Review, chaired by former senior midwife Donna Ockenden, uncovered 1,862 serious incidents involving the maternity services of one NHS trust, including the deaths of hundreds of babies and thirteen mothers, occurring predominantly between 2000-2019. West Mercia Police had already begun its own investigation into whether there were any grounds for criminal proceedings. It is thought that by the time the full report is released at the end of this month, it will be one of the biggest scandals in the history of the NHS.

The trust in question was the Shrewsbury and Telford Hospital Trust (SaTH), where Charlotte lay now, waiting to give birth.

The Ockenden Review was first commissioned in 2017 by then health secretary, Jeremy Hunt, after the parents of Kate Stanton-Davies and Pippa Griffiths, babies who had died while under the trust’s care, raised concern about their cases, along with 21 others. From there, the inquiry ballooned, and with so many other cases emerging, Ockenden had to draw a line under the 1,862 cases that she and her team had already identified.

The report discovered amongst its findings an 'unacceptable' lack of kindness from the staff where some mothers were called 'lazy' and 'pathetic', repeated failings to escalate problems to senior staff as they arose, inappropriate use of drugs including Oxytocin to speed up labour, and families' concerns being 'not listened to at all'. One family was told that they would have to leave if they did not 'keep the noise down' following their child's death and in other cases, the deceased baby was referred to as an 'it'.

Charlotte had no initial misgiving thoughts about having her baby at The Princess Royal Hospital in Telford. "I thought I would be in the best place as my labour would be led by consultants," she says. "I thought that with the investigation going on there, they would be extra careful."

The 27-year-old nursery nurse's pregnancy had been relatively smooth-sailing until she was diagnosed with gestational diabetes at her 32-week scan. Due to her high BMI and the baby being on the larger side, she was classed as a 'high-risk pregnancy' so it was suggested that she should be induced ten days before her due date in mid-December. This was to avoid the risk of the baby getting too big and its shoulders getting stuck in the birth canal.

By 4 o'clock the next morning, her labour was 'failing to progress' so the midwife decided to bring in a consultant to help Charlotte. The consultant made several attempts to pull the baby out. "The forceps were horrendous," she recalls, her face grimacing. "I kept sliding down the bed. Even with its brakes on, the hospital bed kept moving."

Charlotte and Ryan's son Harry finally arrived at 6.22 am on Friday 11 December, weighing a healthy 8lbs 5 ounces. Harry was a much-welcomed blessing after the disappointing year the couple had had. Like so many others in 2020, Charlotte and Ryan had been forced to cancel their spring wedding, as Britain went into its first national lockdown. They eventually married at Shrewsbury Registry Office on the 3 November 2020, just two days before England was plunged into another lockdown.

The new mum describes meeting her baby for the first time as 'amazing' but admits that she did feel concerned. "I was worried that the forceps might have harmed Harry as he had cuts and bruises all over his face, as well as a blister on the top of his head," she says.

This is understandable considering some of the more harrowing findings that emerged from The Ockenden Review. There were several incidents at SaTH where babies' skulls were fractured due to forceps being used with 'excessive force'. Other grim cases included infants being left brain-damaged when staff failed to realise that labour was not progressing, or from group B strep or meningitis infections that could have easily been treated by antibiotics.

Charlotte was left with a second-degree perineal tear, between her vagina and her anus; not uncommon with an assisted delivery such as forceps. She was stitched up by the consultant before being taken back to the maternity ward for some much-needed rest. However, a few hours later, she noticed that she kept passing gas through her vagina. When she mentioned this to a midwife on the ward, Charlotte was told that this was completely normal. But after being discharged the next day, she said that by this stage, it was uncontrollable.

Things came to a head when she woke the following morning to find faeces in her maternity pad and realised that it was coming from her vagina. Ryan rushed her to The Princess Royal Hospital where she was made to wait for five hours in A&E, sitting in her own filth, before she was eventually seen by the Head of Triage and a gynaecologist. After examining her, they told her that there was a tear in her vagina which had also perforated her bowel and that it would need to be operated on at the Colorectal Surgical Unit over sixteen miles away at The Royal Shrewsbury Hospital.

Charlotte recalls having to fight back the tears as she said goodbye to Ryan once the ambulance arrived. "I was heartbroken that I was being taken away from both my son and my husband only three days after giving birth."

After arriving at Shrewsbury, she was seen by a Consultant Colorectal Surgeon, who explained that he would try his best to mend the tear, but as it had been left for so long, the likelihood was that she might have to be fitted with a stoma instead. He informed her that she could face being incontinent for the rest of her life. She was then handed a consent form to sign that notified her that the risk of becoming infertile from the procedure was high. "At this point, I was just in my own little world," she says. "I was past caring."

Charlotte was then told that she might have to wait until the next day before she could even have the operation. "I was scared," she says. "I was worried that the longer they left it, the more likely that an infection might occur."

She was eventually taken down to theatre that evening, where she was operated on for about two hours. Fortunately, the surgeon managed to stitch the tear up, but he warned her that she "wasn’t out of the woods yet" and that she may still need to have a colostomy bag at some point.

During the operation, the surgeon had found an 8 cm buttonhole tear inside her vagina, which the consultant had missed as he had failed to do a routine check on Charlotte. This had then allowed a rectovaginal fistula to form – an abnormal passage between the bowel and the vagina.

Rectovaginal fistulas are extremely rare in Western countries, as they are considered 'a disease of poverty' but are said to be the leading cause of maternal deaths in developing countries, such as Latin America and sub-Saharan Africa. The consequences for women who go on to develop rectovaginal fistulas after childbirth are devastating. Without treatment, the constant leakage of blood, faeces, and urine often leaves the woman ostracized by her community, abandoned by her husband, and unable to work.

Although the repercussions may not have been so dire for Charlotte, the mental toll that the experience has taken on her over a year since Harry’s birth has been just as agonising as the injury itself. "I cry every day. I can't sleep at night, and I'm constantly obsessing about it," she admits.

Charlotte has since had to have a further two operations to try to repair the damage caused during her labour. An internal investigation was carried out into her case, and she is now taking legal action against the trust.


Note: BBC Panorama recently interviewed Charlotte and several other families for its programme: Maternity Scandal: Fighting for The Truth. It is a harrowing but an important tale of how the SaTH maternity scandal came to light, thanks to the diligence of some of the grieving parents affected by its failings. You can watch it here at: BBC iPlayer - Panorama - Maternity Scandal: Fighting for the Truth.