An investigation into the high number of baby deaths at a Shropshire NHS trust in 2022 has identified poor care and problems with the neonatal service.

The Royal College of Physicians review says further investigation is needed into the high mortality across the West Midlands region, as well as at Shrewsbury and Telford Hospital (SaTH) NHS trust.

In relation to seven child deaths, the ‘obstetric journey’ report describes how the issues were handled as poor.

SaTH insisted that the quality of treatment did not contribute to the deaths, but apologized for examples of poor care.

A total of 18 deaths were recorded by SaTH in 2021-22, which was 5% higher than similarly sized trusts.

For the three years prior to this, neonatal mortality had also been high. So the trust invited the Royal College of Physicians (RCP) to review its newborn service.

The period 2021-22 was the time when senior midwife Donna Ockenden was reporting on the SaTH failures that led to 200 deaths – at that stage the biggest maternity scandal in NHS history.

This year the trust was rated good for maternity services by the Care Quality Commission.

The RCP said the overall impression was of a maternity service that had made huge strides over the past two years.

However, the CPR report identified only five cases where there was good practice in 2022. Two were unsatisfactory and 10 had room for improvement.

All cases in the report have been heavily redacted to hide details, but it has been confirmed that Poppy Russell, who died in April 2021 from neglect, was included.

A lawyer representing parents Neil and Katie Russell told the BBC she did not believe the CPR inquiry fully reflected her clients’ concerns.

The report found that the newborn service in 2022 was more fragile than the maternity service and had nurse leadership problems.

He identified a sense of panic at times during infant resuscitation while trying to insert a tube into a child’s lungs.

Delays have also been identified in the ‘golden hour’ after birth, when certain vital interventions, such as the administration of antibiotics, could make a difference.

Staffing deficiencies in neonatal care were identified, with the trust having limited skilled nurses and relying on agency staff.

Shrewsbury and Telford Hospital chief medical officer John Jones said he had written to each of the 18 families whose care for their babies or toddlers had been reviewed and had started meeting them to answer questions and offer support.

“The review team did not find that the quality of care we provide to newborn babies is substandard or has any direct contribution to mortality rates,” he said.

“However, while they described examples of good care, there were also examples of poor care that should have been significantly better. We sincerely apologize for this.”