THE former senior midwife leading an independent inquiry into baby deaths at scandal-hit Shrewsbury and Telford Hospital NHS Trust (SaTH) has told Parliament that a failure to listen to families was the key issue.

Donna Ockenden told the Commons Health and Social Care Committee there was a "culture" of blaming parents.

Last week, Ms Ockenden's interim report identified a number of "deeply worrying themes" about SaTH staff.

Ms Ockenden told the committee on Tuesday: "I think the one issue that stands out above everything else was a failure to listen to families.

"We've come across a lot of families who tried really hard to get the system – the trust – to listen to them.

"They (the parents) carry on their shoulders a large amount of guilt now because they feel they failed to get the system to listen to them."

Ms Ockenden told the committee, chaired by former health secretary Jeremy Hunt: "I can't stress it enough – listening or not listening to families is absolutely key.

"We know many, many families tried over many years to get the trust structure... to listen.

"We have seen lots of examples already of dismissive letters, very unkind letters.

"There was also a culture of 'this is your fault' to the mothers - 'If you hadn't done X, your baby may have lived'."

She added: "Mothers and fathers will tell you they have carried that guilt for years."

Ms Ockenden added that SaTH had its own mechanism for dealing with complaints, which did not follow national guidance, and was only ever engaged when legal action was threatened or a complaint was made.

She told the Commons Health and Social Care Committee: "What we found is that when they did investigate, if they did investigate, they often just hung their hat on the wrong hook.

"They picked something that certainly wasn't the cause and got diverted – they failed to learn.

"It's not one issue – it's not that they tried to sweep things under the carpet, it's not that they just didn't listen to families, there were multi-faceted things going on across all professions."